Provider Demographics
NPI:1760549141
Name:PEDIATRIC HEMATOLOGY ONCOLOGY
Entity Type:Organization
Organization Name:PEDIATRIC HEMATOLOGY ONCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:VICHINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-428-3855
Mailing Address - Street 1:5528 PACHECO BLVD
Mailing Address - Street 2:#A
Mailing Address - City:PACHECO
Mailing Address - State:CA
Mailing Address - Zip Code:94553-5126
Mailing Address - Country:US
Mailing Address - Phone:925-363-8170
Mailing Address - Fax:
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAZZZ77127Z2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ77127ZMedicaid
CAZZZ77127ZOtherBLUE SHIELD
CAZZZ77127ZMedicare ID - Type Unspecified