Provider Demographics
NPI:1669686606
Name:CHARLES O. SLOCUMB MD MED CORP
Entity Type:Organization
Organization Name:CHARLES O. SLOCUMB MD MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:O
Authorized Official - Last Name:SLOCUMB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-576-3832
Mailing Address - Street 1:1541 FLORIDA AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4429
Mailing Address - Country:US
Mailing Address - Phone:209-576-3832
Mailing Address - Fax:
Practice Address - Street 1:1541 FLORIDA AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4429
Practice Address - Country:US
Practice Address - Phone:209-576-3832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30130207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07710ZMedicare PIN