Provider Demographics
NPI:1154372951
Name:DE, INDRA (MD, PHD)
Entity type:Individual
Prefix:
First Name:INDRA
Middle Name:
Last Name:DE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 GLEN ABBY CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-1800
Mailing Address - Country:US
Mailing Address - Phone:209-462-9100
Mailing Address - Fax:209-462-9101
Practice Address - Street 1:1800 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6019
Practice Address - Country:US
Practice Address - Phone:209-943-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2022-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52396207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTI31758Medicare UPIN