Provider Demographics
NPI:1083890990
Name:SANTA CLARA OB/GYN MEDICAL GROUP
Entity Type:Organization
Organization Name:SANTA CLARA OB/GYN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-993-1814
Mailing Address - Street 1:PO BOX 5040
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95150-5040
Mailing Address - Country:US
Mailing Address - Phone:408-488-9211
Mailing Address - Fax:408-448-2743
Practice Address - Street 1:2030 FOREST AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4833
Practice Address - Country:US
Practice Address - Phone:408-993-1814
Practice Address - Fax:408-993-1822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34509207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0030630Medicaid