1912919358 NPI number — VALLEY PODIATRY GROUP INC

Table of content: CIORSTI JEAN MACINTYRE MD (NPI 1285031088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912919358 NPI number — VALLEY PODIATRY GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY PODIATRY GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912919358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3031 W MARCH LANE
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95219-6500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-472-0800
Provider Business Mailing Address Fax Number:
209-472-1203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3031 W MARCH LANE
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95219-6500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-472-0800
Provider Business Practice Location Address Fax Number:
209-472-1203
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHIMOZAKI
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
209-472-0800

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GRE001670 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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