Provider Demographics
NPI:1790712990
Name:PACIFIC HEART AND VASCULAR MEDICAL GROUP
Entity Type:Organization
Organization Name:PACIFIC HEART AND VASCULAR MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-464-3615
Mailing Address - Street 1:1801 E MARCH LN
Mailing Address - Street 2:SUITE D400
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6629
Mailing Address - Country:US
Mailing Address - Phone:209-464-3615
Mailing Address - Fax:209-464-1311
Practice Address - Street 1:845 S FAIRMONT AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5113
Practice Address - Country:US
Practice Address - Phone:209-334-0651
Practice Address - Fax:209-334-5013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP33233207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ59847ZOtherBC/BS GRP PROVIDER #
CAGR0086060Medicaid
CA060057321OtherRAILROAD MEDICARE GROUP #