Provider Demographics
NPI:1295175321
Name:CENTRAL CALIFORNIA MEDICAL GROUP
Entity type:Organization
Organization Name:CENTRAL CALIFORNIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:
Authorized Official - Last Name:SUESBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-721-5201
Mailing Address - Street 1:432 LEXINGTON ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-3697
Mailing Address - Country:US
Mailing Address - Phone:661-375-5871
Mailing Address - Fax:661-375-5877
Practice Address - Street 1:432 LEXINGTON ST UNIT A
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-3697
Practice Address - Country:US
Practice Address - Phone:661-375-5871
Practice Address - Fax:661-375-5877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29033208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA105918Medicare Oscar/Certification