1497762751 NPI number — REYNA-ATHENA SAMALEA DAVID DPT

Table of content: REYNA-ATHENA SAMALEA DAVID DPT (NPI 1497762751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497762751 NPI number — REYNA-ATHENA SAMALEA DAVID DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVID
Provider First Name:
REYNA-ATHENA
Provider Middle Name:
SAMALEA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1497762751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18780 COX AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARATOGA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95070-4109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-973-7700
Provider Business Mailing Address Fax Number:
408-973-1600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12900 SARATOGA AVE
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
SARATOGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95070-4666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-354-2223
Provider Business Practice Location Address Fax Number:
408-354-2228
Provider Enumeration Date:
08/01/2006

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: 225100000X , with the licence number:  PT32919 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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