Provider Demographics
NPI:1811222391
Name:DAMIEN, DEEPTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:DEEPTHY
Middle Name:
Last Name:DAMIEN
Suffix:
Gender:F
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-0779
Mailing Address - Country:US
Mailing Address - Phone:209-373-2800
Mailing Address - Fax:
Practice Address - Street 1:730 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-4104
Practice Address - Country:US
Practice Address - Phone:209-820-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine