1306840186 NPI number — DR. DIXIE IMADA PH.D.

Table of content: DR. DIXIE IMADA PH.D. (NPI 1306840186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306840186 NPI number — DR. DIXIE IMADA PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IMADA
Provider First Name:
DIXIE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1306840186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4910 PHELPS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMICHAEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95608-6208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-359-5244
Provider Business Mailing Address Fax Number:
916-486-0188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4748 ENGLE RD
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
CARMICHAEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95608-2232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-752-9996
Provider Business Practice Location Address Fax Number:
916-486-0188
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  AU643 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 237600000X , with the licence number: HA4075 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: AU0006430 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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