Provider Demographics
NPI:1649275330
Name:HOM, LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:LOUISE
Middle Name:
Last Name:HOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20130 LAKE CHABOT RD
Mailing Address - Street 2:STE 202
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20130 LAKE CHABOT RD
Practice Address - Street 2:STE 202
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5340
Practice Address - Country:US
Practice Address - Phone:510-583-8192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62353208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G623531Medicare PIN
CAF37473Medicare UPIN
CAZZZ01488ZMedicare PIN