Provider Demographics
NPI:1881745313
Name:VESCERA, SAMUEL V (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:V
Last Name:VESCERA
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:PO BOX 7156
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0156
Mailing Address - Country:US
Mailing Address - Phone:209-467-6866
Mailing Address - Fax:
Practice Address - Street 1:10200 TRINITY PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-7249
Practice Address - Country:US
Practice Address - Phone:209-323-3480
Practice Address - Fax:209-472-9102
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27029207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G270290Medicaid
CA00G270290Medicare ID - Type Unspecified