Provider Demographics
NPI:1225455488
Name:HAN, BOB
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:
Last Name:HAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E HACIENDA AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-6617
Mailing Address - Country:US
Mailing Address - Phone:408-871-5854
Mailing Address - Fax:
Practice Address - Street 1:200 E HACIENDA AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008
Practice Address - Country:US
Practice Address - Phone:408-871-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A158262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program