Provider Demographics
NPI:1780119966
Name:NORCAL PEDIATRIC GASTROENTEROLOGY
Entity type:Organization
Organization Name:NORCAL PEDIATRIC GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:HADDAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-813-4747
Mailing Address - Street 1:8275 ROYALL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-9340
Mailing Address - Country:US
Mailing Address - Phone:510-813-4747
Mailing Address - Fax:877-992-2989
Practice Address - Street 1:1776 YGNACIO VALLEY RD
Practice Address - Street 2:STE 108
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3190
Practice Address - Country:US
Practice Address - Phone:925-939-9200
Practice Address - Fax:925-939-9205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC515752080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF92979Medicare UPIN