Provider Demographics
NPI:1578515045
Name:SAN JOAQUIN HEMATOLOGY/ONCOLOGY A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:SAN JOAQUIN HEMATOLOGY/ONCOLOGY A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NEELESH
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGALORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:209-839-9115
Mailing Address - Street 1:PO BOX 7667
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0667
Mailing Address - Country:US
Mailing Address - Phone:209-474-1458
Mailing Address - Fax:209-474-1444
Practice Address - Street 1:1801 E MARCH LN STE B260
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6655
Practice Address - Country:US
Practice Address - Phone:209-474-1458
Practice Address - Fax:209-474-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70883174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ08571ZOtherBLUE SHIELD
CA00A708832OtherMEDI-CAL
CAP00186385OtherRAILROAD MEDICARE
CA00A708830OtherMEDICARE
CA00A708831Medicaid
CADC7234OtherRAILROAD MEDICARE
CADC7234OtherRAILROAD MEDICARE
CADC7234OtherRAILROAD MEDICARE
CA00A708832OtherMEDI-CAL