1992891295 NPI number — STEPHEN LINDSAY VILTRAKIS M D

Table of content: STEPHEN LINDSAY VILTRAKIS M D (NPI 1992891295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992891295 NPI number — STEPHEN LINDSAY VILTRAKIS M D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VILTRAKIS
Provider First Name:
STEPHEN
Provider Middle Name:
LINDSAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M D
Provider Gender Code:
M

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:
1992891295
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P. O. BOX 6640
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUREKA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-445-5431
Provider Business Mailing Address Fax Number:
707-445-3710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 RENNER DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORTUNA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-725-3361
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  G72357 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00G723570 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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