Provider Demographics
NPI:1992423685
Name:MANTECA GASTROENTEROLOGY GROUP
Entity type:Organization
Organization Name:MANTECA GASTROENTEROLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RIPUDAMAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BENIWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-239-0515
Mailing Address - Street 1:1144 NORMAN DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-5959
Mailing Address - Country:US
Mailing Address - Phone:209-239-0515
Mailing Address - Fax:
Practice Address - Street 1:1144 NORMAN DR STE 101
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5959
Practice Address - Country:US
Practice Address - Phone:209-239-0515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-18
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty