Provider Demographics
NPI:1891766093
Name:PANGANIBAN, WALTER G (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:G
Last Name:PANGANIBAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 SAFFRON DR
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-8669
Mailing Address - Country:US
Mailing Address - Phone:925-963-3184
Mailing Address - Fax:
Practice Address - Street 1:5565 W LAS POSITAS BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-4001
Practice Address - Country:US
Practice Address - Phone:925-416-3562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A258370Medicaid
CA00A258370Medicare ID - Type Unspecified
CA00A258370Medicaid