Provider Demographics
NPI:1790910610
Name:CALIFORNIA PRIMARY CARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CALIFORNIA PRIMARY CARE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OTASHE
Authorized Official - Middle Name:NYOKU
Authorized Official - Last Name:GOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-837-1966
Mailing Address - Street 1:530 W ACACIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-2454
Mailing Address - Country:US
Mailing Address - Phone:916-944-5550
Mailing Address - Fax:
Practice Address - Street 1:530 W ACACIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2454
Practice Address - Country:US
Practice Address - Phone:209-944-5550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
CAA70035261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH05578Medicare UPIN