Provider Demographics
NPI:1457657116
Name:UNIVERSITY OF CALIFORNIA SAN FRANCISCO FRESNO
Entity Type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA SAN FRANCISCO FRESNO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-499-6466
Mailing Address - Street 1:155 N FRESNO ST
Mailing Address - Street 2:SUITE # 326
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701-2302
Mailing Address - Country:US
Mailing Address - Phone:559-499-6466
Mailing Address - Fax:
Practice Address - Street 1:155 N FRESNO ST
Practice Address - Street 2:SUITE # 326
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2302
Practice Address - Country:US
Practice Address - Phone:559-499-6466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization