Provider Demographics
NPI:1942692140
Name:WILLOW GLEN PRIMARY CARE MEDICINE
Entity Type:Organization
Organization Name:WILLOW GLEN PRIMARY CARE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDSAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-460-5869
Mailing Address - Street 1:1226 LINCOLN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-3025
Mailing Address - Country:US
Mailing Address - Phone:408-460-5869
Mailing Address - Fax:
Practice Address - Street 1:1226 LINCOLN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-3025
Practice Address - Country:US
Practice Address - Phone:408-460-5869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
YYY20599YMedicare UPIN