Provider Demographics
NPI:1659413664
Name:FEDERAL, WILLIAM AUBREY (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:AUBREY
Last Name:FEDERAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5525
Mailing Address - Country:US
Mailing Address - Phone:209-467-1000
Mailing Address - Fax:209-467-7335
Practice Address - Street 1:546 E PINE ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5525
Practice Address - Country:US
Practice Address - Phone:209-467-1000
Practice Address - Fax:209-467-7335
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC359052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659413664Medicaid
CABH296YMedicare PIN