Provider Demographics
NPI:1396960605
Name:SALLY E NACIANCENO MD INC
Entity type:Organization
Organization Name:SALLY E NACIANCENO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:E
Authorized Official - Last Name:NACIANCENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-251-3364
Mailing Address - Street 1:175 N JACKSON AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1909
Mailing Address - Country:US
Mailing Address - Phone:408-251-3364
Mailing Address - Fax:
Practice Address - Street 1:175 N JACKSON AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1909
Practice Address - Country:US
Practice Address - Phone:408-251-3364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29762207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29762OtherMEDICAL LICENSE NO.
CA=========OtherTAX ID
CAA29762OtherMEDICAL LICENSE NO.