Provider Demographics
NPI:1649253881
Name:CAMACHO, RICHARD O (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:O
Last Name:CAMACHO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 N CALIFORNIA ST STE 406
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-6033
Mailing Address - Country:US
Mailing Address - Phone:209-227-7806
Mailing Address - Fax:209-851-3853
Practice Address - Street 1:1805 N CALIFORNIA ST STE 406
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6033
Practice Address - Country:US
Practice Address - Phone:209-227-7806
Practice Address - Fax:209-851-3853
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2018-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93056207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR233118Medicaid
OR119961Medicare ID - Type Unspecified
I11415Medicare UPIN