Provider Demographics
NPI:1528003597
Name:HOLLANDER, ETHAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:D
Last Name:HOLLANDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 34929
Mailing Address - Street 2:P.O. BOX 39000
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94139-0001
Mailing Address - Country:US
Mailing Address - Phone:925-952-2828
Mailing Address - Fax:925-952-2850
Practice Address - Street 1:2305 CAMINO RAMON
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1396
Practice Address - Country:US
Practice Address - Phone:925-837-1886
Practice Address - Fax:925-837-3913
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78030207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A780300Medicaid
CAP00103585Medicare PIN
CAH94332Medicare UPIN
CA00A780300Medicaid