Provider Demographics
NPI:1639366586
Name:PRIMA MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:PRIMA MEDICAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MONDRAGON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-884-1840
Mailing Address - Street 1:4 HAMILTON LNDG
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-8256
Mailing Address - Country:US
Mailing Address - Phone:415-884-1840
Mailing Address - Fax:415-884-3510
Practice Address - Street 1:165 ROWLAND WAY STE 100
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5055
Practice Address - Country:US
Practice Address - Phone:415-898-4211
Practice Address - Fax:415-898-9252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30247207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44349Medicare UPIN
CA4286600001Medicare NSC