1477121903 NPI number — GAZEBO MEDICAL CORPORATION, P.C.

Table of content: JAMES DAVID HICKMAN MMF (NPI 1083299762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477121903 NPI number — GAZEBO MEDICAL CORPORATION, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GAZEBO MEDICAL CORPORATION, P.C.
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:
1477121903
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
142 CRESCENT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTOLA VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94028-7821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-714-2411
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
142 CRESCENT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTOLA VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94028-7821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-714-2411
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2021

Additional Information

Authorized Official

Authorized Official Last Name:
DOWNING
Authorized Official First Name:
NORMAN
Authorized Official Middle Name:
LANCE
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
650-260-5631

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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