Provider Demographics
NPI:1649618737
Name:SOUTH BAY HOUSECALL DOCTOR INC
Entity type:Organization
Organization Name:SOUTH BAY HOUSECALL DOCTOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:408-835-9977
Mailing Address - Street 1:3640 SWEIGERT RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2448
Mailing Address - Country:US
Mailing Address - Phone:408-835-9977
Mailing Address - Fax:800-818-0931
Practice Address - Street 1:3640 SWEIGERT RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95132-2448
Practice Address - Country:US
Practice Address - Phone:408-835-9977
Practice Address - Fax:800-818-0931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8549207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH99198Medicare UPIN