1215048632 NPI number — DR. HAYWARD CLINTON MABEN III M.D.

Table of content: DR. HAYWARD CLINTON MABEN III M.D. (NPI 1215048632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215048632 NPI number — DR. HAYWARD CLINTON MABEN III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MABEN
Provider First Name:
HAYWARD
Provider Middle Name:
CLINTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1215048632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 DOLORES ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94110-1008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-613-4789
Provider Business Mailing Address Fax Number:
415-861-7779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 WEBSTER ST
Provider Second Line Business Practice Location Address:
SUITE 1010
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94609-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-451-1875
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006

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: 207L00000X , with the licence number:  G68853 , 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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