Provider Demographics
NPI:1912919358
Name:VALLEY PODIATRY GROUP INC
Entity Type:Organization
Organization Name:VALLEY PODIATRY GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHIMOZAKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:209-472-0800
Mailing Address - Street 1:3031 W MARCH LANE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-6500
Mailing Address - Country:US
Mailing Address - Phone:209-472-0800
Mailing Address - Fax:209-472-1203
Practice Address - Street 1:3031 W MARCH LANE
Practice Address - Street 2:SUITE 310
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-6500
Practice Address - Country:US
Practice Address - Phone:209-472-0800
Practice Address - Fax:209-472-1203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE001670Medicaid
CA4800910001Medicare NSC
CAGRE001670Medicaid