Provider Demographics
NPI:1013977461
Name:DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF CALIFORNIA INC
Entity Type:Organization
Organization Name:DAVITA NEPHROLOGY MEDICAL ASSOCIATES OF CALIFORNIA INC
Other - Org Name:DAVITA RENAL SPECIALISTS OF CALIFORNIA MEDICAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-626-6103
Mailing Address - Street 1:1360 BURTON DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-3557
Mailing Address - Country:US
Mailing Address - Phone:707-466-4379
Mailing Address - Fax:707-446-4417
Practice Address - Street 1:1360 BURTON DR
Practice Address - Street 2:SUITE 160
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-3539
Practice Address - Country:US
Practice Address - Phone:707-446-4379
Practice Address - Fax:707-446-4417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADA5762OtherRR RET BOARD MED RR CARR
CAZZZ21333ZMedicare PIN
CAZZZ27071ZMedicare PIN