Provider Demographics
NPI:1134179237
Name:TASSAJARA VALLEY MEDICAL GROUP PC
Entity type:Organization
Organization Name:TASSAJARA VALLEY MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAAFAT
Authorized Official - Middle Name:K
Authorized Official - Last Name:ZAMARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-443-8040
Mailing Address - Street 1:1258 CONCANNON BLVD
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-6002
Mailing Address - Country:US
Mailing Address - Phone:925-443-8040
Mailing Address - Fax:925-443-1065
Practice Address - Street 1:1258 CONCANNON BLVD
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-6002
Practice Address - Country:US
Practice Address - Phone:925-443-8040
Practice Address - Fax:925-443-1065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0091680Medicaid
CAGR0091680Medicaid