Provider Demographics
NPI:1659399202
Name:PACIFIC WOUND CENTER MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PACIFIC WOUND CENTER MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL,(PER PECO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:209-476-0675
Mailing Address - Street 1:4722 QUAIL LAKES DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5256
Mailing Address - Country:US
Mailing Address - Phone:209-476-0675
Mailing Address - Fax:209-476-9389
Practice Address - Street 1:4722 QUAIL LAKES DR
Practice Address - Street 2:SUITE A
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5256
Practice Address - Country:US
Practice Address - Phone:209-476-0675
Practice Address - Fax:209-476-9389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74876207R00000X
CAA31110207RC0000X
CAE3287213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07794ZOtherBLUE SHIELD
ZZZ07794ZOtherBLUE SHIELD
CAZZZ28592ZMedicare PIN
ZZZ28592ZMedicare PIN