Provider Demographics
NPI:1215905260
Name:PRIMACK, DAREN STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:DAREN
Middle Name:STEPHEN
Last Name:PRIMACK
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 1:1801 E MARCH LN
Mailing Address - Street 2:STE. D400
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6629
Mailing Address - Country:US
Mailing Address - Phone:209-464-3615
Mailing Address - Fax:209-464-1311
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:STE. D400
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-464-3615
Practice Address - Fax:209-464-1311
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68135207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G681350Medicaid
CAG68135OtherMEDICAL LICENSE NUMBER
CAG68135OtherMEDICAL LICENSE NUMBER
CAF84250Medicare UPIN
CA00G535851Medicare PIN
CA00G535852Medicare PIN
CA00G535853Medicare PIN