Provider Demographics
NPI:1649234865
Name:FAMILY PRACTICE MEDICAL GROUP OF OAKLAND
Entity Type:Organization
Organization Name:FAMILY PRACTICE MEDICAL GROUP OF OAKLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAREEN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-419-0230
Mailing Address - Street 1:350 30TH ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3425
Mailing Address - Country:US
Mailing Address - Phone:510-419-0230
Mailing Address - Fax:510-419-0440
Practice Address - Street 1:350 30TH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3425
Practice Address - Country:US
Practice Address - Phone:510-419-0230
Practice Address - Fax:510-419-0440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ45714ZOtherBLUE SHIELD
CAZZZ45714ZOtherBLUE SHIELD