1477544229 NPI number — LOS GATOS RADIATION ONCOLOGY MEDICAL ASSOCIATES

Table of content: DR. MARIELLE KATHLEEN DIVILBISS DEMARAIS PHD, LP (NPI 1194159392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477544229 NPI number — LOS GATOS RADIATION ONCOLOGY MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOS GATOS RADIATION ONCOLOGY MEDICAL ASSOCIATES
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:
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:
1477544229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4301 NORTHSTAR WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95356-9262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-342-2300
Provider Business Mailing Address Fax Number:
209-524-4240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15400 NATIONAL AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
LOS GATOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95032-2433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-342-2300
Provider Business Practice Location Address Fax Number:
209-524-4240
Provider Enumeration Date:
11/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PEDDADA
Authorized Official First Name:
ABBINAND
Authorized Official Middle Name:
VENKATA
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
209-342-2300

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , 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: GR0087740 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ62315Z . This is a "BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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