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

Table of Contents

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:
Provider Other Organization Name Type Code:
6
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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