1972641736 NPI number — EVERGREEN PEDIATRICS INC

Table of content: (NPI 1972641736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972641736 NPI number — EVERGREEN PEDIATRICS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN PEDIATRICS 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:
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:
1972641736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4205 SAN FELIPE RD
Provider Second Line Business Mailing Address:
#110
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95135-1503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-238-8303
Provider Business Mailing Address Fax Number:
408-238-8375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4205 SAN FELIPE RD
Provider Second Line Business Practice Location Address:
#110
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95135-1503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-238-8303
Provider Business Practice Location Address Fax Number:
408-238-8375
Provider Enumeration Date:
02/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NIGAM
Authorized Official First Name:
PRONOTI
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
408-238-8303

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  A33613 , 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: 00C431251 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A336130 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: R09208 . This is a "BLUE CROSS MEDICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1053390310 . This is a "PRONOTI NIGAM MD NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1750497608 . This is a "ZAHIDA P MALIKMD NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: R09238 . This is a "BLUE CROSS MEDICAL" identifier . This identifiers is of the category "OTHER".




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