Provider Demographics
NPI:1477587897
Name:TERRA LINDA PEDIATRICS
Entity Type:Organization
Organization Name:TERRA LINDA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YAMAGUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-479-8642
Mailing Address - Street 1:4000 CIVIC CENTER DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4171
Mailing Address - Country:US
Mailing Address - Phone:415-479-8642
Mailing Address - Fax:415-479-2434
Practice Address - Street 1:4000 CIVIC CENTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4171
Practice Address - Country:US
Practice Address - Phone:415-479-8642
Practice Address - Fax:415-479-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0017000Medicare ID - Type Unspecified