1164514881 NPI number — EITAN HOMA MD AND JENNIFER KRASNOFF MD INC

Table of content: (NPI 1164514881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164514881 NPI number — EITAN HOMA MD AND JENNIFER KRASNOFF MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EITAN HOMA MD AND JENNIFER KRASNOFF MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DERMATOLOGY ASSOCIATES OF THE BAY AREA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164514881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 ALFRED NOBEL DR
Provider Second Line Business Mailing Address:
STE 245
Provider Business Mailing Address City Name:
HERCULES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-741-7418
Provider Business Mailing Address Fax Number:
510-741-7456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 ALFRED NOBEL DR
Provider Second Line Business Practice Location Address:
STE 245
Provider Business Practice Location Address City Name:
HERCULES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-741-7418
Provider Business Practice Location Address Fax Number:
510-741-7456
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOLE
Authorized Official First Name:
MARLENE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
510-741-7418

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZ00647Z . This is a "BLUE SHILED" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: C14303 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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