Provider Demographics
NPI:1902828841
Name:STANISLAUS CARDIOLOGY GROUP
Entity Type:Organization
Organization Name:STANISLAUS CARDIOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:HON-WAH
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-521-9661
Mailing Address - Street 1:3621 FOREST GLENN DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1339
Mailing Address - Country:US
Mailing Address - Phone:209-521-9661
Mailing Address - Fax:209-521-9307
Practice Address - Street 1:3621 FOREST GLENN DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1339
Practice Address - Country:US
Practice Address - Phone:209-521-9661
Practice Address - Fax:209-521-9307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP 30072174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902828841Medicaid
CAZZZ23413ZMedicare PIN