Provider Demographics
NPI:1790844769
Name:PEDIATRIC CARE OF STOCKTON
Entity Type:Organization
Organization Name:PEDIATRIC CARE OF STOCKTON
Other - Org Name:PEDIATRIC CARE OF STOCKTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SURESH
Authorized Official - Middle Name:K
Authorized Official - Last Name:SACHDEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-464-2695
Mailing Address - Street 1:2800 N CALIFORNIA STREET
Mailing Address - Street 2:SUITE 14
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-3759
Mailing Address - Country:US
Mailing Address - Phone:209-464-2605
Mailing Address - Fax:209-464-2711
Practice Address - Street 1:2800 N CALIFORNIA STREET
Practice Address - Street 2:SUITE 14
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-3759
Practice Address - Country:US
Practice Address - Phone:209-464-2605
Practice Address - Fax:209-464-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64522208000000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA64522OtherMEDICAL LICENSE NUMBER
CA00A645220Medicaid
CA00A645220Medicaid