Provider Demographics
NPI:1538137963
Name:DEPHILLIPS, JOANNE (MD)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:DEPHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2070 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4399
Mailing Address - Country:US
Mailing Address - Phone:510-814-4397
Mailing Address - Fax:510-814-4391
Practice Address - Street 1:2070 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4399
Practice Address - Country:US
Practice Address - Phone:510-814-4397
Practice Address - Fax:510-814-4391
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G346000Medicaid
A45996Medicare UPIN
00G346002Medicare ID - Type Unspecified