Provider Demographics
NPI:1104238104
Name:GALICIA, SAMUEL ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ANTONIO
Last Name:GALICIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 W YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-5130
Mailing Address - Country:US
Mailing Address - Phone:209-825-3700
Mailing Address - Fax:
Practice Address - Street 1:1721 W YOSEMITE AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-5130
Practice Address - Country:US
Practice Address - Phone:209-825-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-24
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA145065207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty