Provider Demographics
NPI:1477968741
Name:PRESTIGE MED INC
Entity type:Organization
Organization Name:PRESTIGE MED INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:Y
Authorized Official - Last Name:MARDANZAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-736-1000
Mailing Address - Street 1:11030 BOLLINGER CANYON RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-4874
Mailing Address - Country:US
Mailing Address - Phone:925-736-1000
Mailing Address - Fax:925-736-1055
Practice Address - Street 1:11030 BOLLINGER CANYON RD
Practice Address - Street 2:SUITE 240
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94582-4874
Practice Address - Country:US
Practice Address - Phone:925-736-1000
Practice Address - Fax:925-736-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80856207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGF086AMedicare PIN