Provider Demographics
NPI:1063803203
Name:SACRAMENTO PEDIATRICS MEDICAL GROUP
Entity type:Organization
Organization Name:SACRAMENTO PEDIATRICS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-422-6635
Mailing Address - Street 1:7237 E SOUTHGATE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2637
Mailing Address - Country:US
Mailing Address - Phone:916-422-6635
Mailing Address - Fax:
Practice Address - Street 1:7501 HOSPITAL DR
Practice Address - Street 2:SUITE 206
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5405
Practice Address - Country:US
Practice Address - Phone:916-682-7481
Practice Address - Fax:916-422-6500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34512208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty