Provider Demographics
NPI:1801125836
Name:G&R MEDICAL CORPORATION
Entity type:Organization
Organization Name:G&R MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:GODFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-908-8343
Mailing Address - Street 1:PO BOX 660877
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95866-0877
Mailing Address - Country:US
Mailing Address - Phone:916-481-0777
Mailing Address - Fax:916-977-1265
Practice Address - Street 1:1200 B GALE WILSON BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3552
Practice Address - Country:US
Practice Address - Phone:916-481-0777
Practice Address - Fax:916-977-1265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102650207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABE729Medicare UPIN