Provider Demographics
NPI:1013123496
Name:SAN JOAQUIN HEMATOLOGY ONCOLOGY A PC
Entity Type:Organization
Organization Name:SAN JOAQUIN HEMATOLOGY ONCOLOGY A PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NEELESH
Authorized Official - Middle Name:S
Authorized Official - Last Name:BANGALORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:209-839-9115
Mailing Address - Street 1:PO BOX 7667
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0667
Mailing Address - Country:US
Mailing Address - Phone:209-839-9115
Mailing Address - Fax:209-833-7262
Practice Address - Street 1:4600 S TRACY BLVD STE 108
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-8105
Practice Address - Country:US
Practice Address - Phone:209-839-9115
Practice Address - Fax:209-833-7262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70883174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5337360001OtherDMERC NUMBER
CA5337360001Medicare NSC