Provider Demographics
NPI:1023169471
Name:DELTA PODIATRY GROUP, INC.
Entity type:Organization
Organization Name:DELTA PODIATRY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:209-464-7367
Mailing Address - Street 1:1205 N HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1409
Mailing Address - Country:US
Mailing Address - Phone:209-464-7367
Mailing Address - Fax:209-464-1801
Practice Address - Street 1:1205 N HUNTER ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1409
Practice Address - Country:US
Practice Address - Phone:209-464-7367
Practice Address - Fax:209-464-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-14
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1406213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE1406OtherLICENSE NUMBER
CAZZZ73253ZMedicaid
CAE1406OtherLICENSE NUMBER
CAZZZ25718ZMedicare ID - Type Unspecified
CAZZZ73253ZMedicaid