Provider Demographics
NPI:1154424299
Name:ANTIOCH MEDICAL PARK MEDICAL GROUP
Entity type:Organization
Organization Name:ANTIOCH MEDICAL PARK MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR MD
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-754-9223
Mailing Address - Street 1:3737 LONE TREE WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6065
Mailing Address - Country:US
Mailing Address - Phone:925-754-9223
Mailing Address - Fax:925-754-3945
Practice Address - Street 1:3737 LONE TREE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6065
Practice Address - Country:US
Practice Address - Phone:925-754-9223
Practice Address - Fax:925-754-3945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA19234207Q00000X
CAG44114207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76320ZMedicaid
CAZZZ76320ZMedicare PIN