Provider Demographics
NPI:1063698041
Name:VIRGILIO C. ERESO M.D. INC.
Entity type:Organization
Organization Name:VIRGILIO C. ERESO M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGILIO
Authorized Official - Middle Name:C
Authorized Official - Last Name:ERESO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-579-7461
Mailing Address - Street 1:500 COFFEE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4926
Mailing Address - Country:US
Mailing Address - Phone:209-579-7461
Mailing Address - Fax:209-579-7465
Practice Address - Street 1:500 COFFEE RD
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4926
Practice Address - Country:US
Practice Address - Phone:209-579-7461
Practice Address - Fax:209-579-7465
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIRGILIO C. ERESO M.D. INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-21
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30308261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA303080Medicaid
CAA303080Medicare PIN
CAA26047Medicare UPIN