Provider Demographics
NPI:1982958351
Name:SACRAMENTO PEDIATRIC GASTROENTEROLOGY,INC.
Entity Type:Organization
Organization Name:SACRAMENTO PEDIATRIC GASTROENTEROLOGY,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC GASTROENTEROLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:YINKA
Authorized Official - Middle Name:KARI
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-332-1244
Mailing Address - Street 1:5767 GREENBACK LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-2013
Mailing Address - Country:US
Mailing Address - Phone:916-332-1244
Mailing Address - Fax:916-760-4147
Practice Address - Street 1:5767 GREENBACK LN
Practice Address - Street 2:SUITE 200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-2013
Practice Address - Country:US
Practice Address - Phone:916-332-1244
Practice Address - Fax:916-760-4147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71235261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A721350Medicaid
CAH82911Medicare UPIN