Provider Demographics
NPI:1104145861
Name:DON MICHAEL ENDRESS MD
Entity type:Organization
Organization Name:DON MICHAEL ENDRESS MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DE LA TORRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-874-2345
Mailing Address - Street 1:2416 CANASTA CT
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:CA
Mailing Address - Zip Code:95329-9633
Mailing Address - Country:US
Mailing Address - Phone:209-852-2765
Mailing Address - Fax:209-852-2766
Practice Address - Street 1:3191 EL PRADO RD
Practice Address - Street 2:SUITE D
Practice Address - City:LA GRANGE
Practice Address - State:CA
Practice Address - Zip Code:95329-9761
Practice Address - Country:US
Practice Address - Phone:209-852-2764
Practice Address - Fax:209-852-2766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTA53357208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A533570Medicaid