Provider Demographics
NPI:1932148343
Name:CENTRAL STOCKTON MEDICAL CLINIC
Entity Type:Organization
Organization Name:CENTRAL STOCKTON MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-948-5515
Mailing Address - Street 1:1144 NORMAN DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-5925
Mailing Address - Country:US
Mailing Address - Phone:209-823-1152
Mailing Address - Fax:209-823-3376
Practice Address - Street 1:1508 WEST LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-3340
Practice Address - Country:US
Practice Address - Phone:209-948-2886
Practice Address - Fax:209-948-2831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ25352ZOtherGROUP PTAN
CAZZZ25352ZMedicare PIN