Provider Demographics
NPI:1962436139
Name:MCOMBER, EARL DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:EARL
Middle Name:DAVID
Last Name:MCOMBER
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 1:2805 PARK OAK DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-2019
Mailing Address - Country:US
Mailing Address - Phone:209-368-7255
Mailing Address - Fax:209-368-7255
Practice Address - Street 1:1801 E MARCH LN BLDG D # 470
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-507-7000
Practice Address - Fax:209-507-7009
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57916174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G57916Medicaid
CAA53348Medicare UPIN
CA00G57916Medicare ID - Type UnspecifiedMEDICARE PROVIDER #