Provider Demographics
NPI:1154326262
Name:BANGALORE, NEELESH S (MD, PHD)
Entity Type:Individual
Prefix:
First Name:NEELESH
Middle Name:S
Last Name:BANGALORE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7667
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0667
Mailing Address - Country:US
Mailing Address - Phone:209-839-9115
Mailing Address - Fax:209-833-7262
Practice Address - Street 1:4600 S TRACY BLVD STE 108
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-8105
Practice Address - Country:US
Practice Address - Phone:209-839-9115
Practice Address - Fax:209-833-7262
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70883174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA900085684OtherTAX ID
CADC7234OtherRAILROAD
CAZZZ08571ZOtherBLUE SHIELD
CA00A708832OtherMEDI CAL
CA00A708831Medicaid
CAP00186385OtherRAILROAD
CA00A708832OtherMEDI CAL
CAA70883Medicare ID - Type Unspecified
CA900085684OtherTAX ID