Individual
JEFFREY O MCGILLICUDDY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1234 E NORTH ST, SUITE 103, MANTECA, CA 95336-4960
(209) 647-3101
(209) 529-8378
Mailing address
199 REYNOLDS ROAD, CHESTER, CA 96020
(530) 258-2826
(530) 258-2802
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
G84589
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G845890
—
CA
05
—
500665638
—
OR
Enumeration date
09/13/2006
Last updated
02/11/2021
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