Organization
PACIFIC HEART AND VASCULAR MEDICAL GROUP
Active
Organization
PACIFIC HEART AND VASCULAR MEDICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KATHERINE BOHNA (SUPERVISOR)
(209) 464-3615
Entity
Organization
Contact information
Practice address
845 S FAIRMONT AVE, SUITE 11, LODI, CA 95240-5113
(209) 334-0651
(209) 334-5013
Mailing address
1801 E MARCH LN, SUITE D400, STOCKTON, CA 95210-6629
(209) 464-3615
(209) 464-1311
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
FNP33233
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
060057321
RAILROAD MEDICARE GROUP #
CA
05
—
GR0086060
—
CA
01
—
ZZZ59847Z
BC/BS GRP PROVIDER #
CA
Enumeration date
06/26/2006
Last updated
03/02/2020
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