1578858502 NPI number — BERTHA TIRADO LIZARRAGA

Table of content: BERTHA TIRADO LIZARRAGA (NPI 1578858502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578858502 NPI number — BERTHA TIRADO LIZARRAGA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIZARRAGA
Provider First Name:
BERTHA
Provider Middle Name:
TIRADO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1578858502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2625 ZANKER RD
Provider Second Line Business Mailing Address:
101
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95134-2130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-325-5219
Provider Business Mailing Address Fax Number:
408-944-0468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2625 ZANKER RD
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95134-2130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-325-5219
Provider Business Practice Location Address Fax Number:
408-944-0468
Provider Enumeration Date:
06/17/2011

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: 171M00000X , with the licence number:  009005 , 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)

  • Identifier: 009005 . This is a "FDC CREDENTIALS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 000 . This is a "000" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 41528 . This is a "UNICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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