Provider Demographics
NPI:1558614073
Name:PACIFIC PARTNERS MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:PACIFIC PARTNERS MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:J. KERSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-274-1654
Mailing Address - Street 1:987 UNIVERSITY AVE
Mailing Address - Street 2:12
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-7640
Mailing Address - Country:US
Mailing Address - Phone:650-358-5800
Mailing Address - Fax:
Practice Address - Street 1:1569 LEXANN AVE
Practice Address - Street 2:128
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1794
Practice Address - Country:US
Practice Address - Phone:408-274-1654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGY770AMedicare PIN