Provider Demographics
NPI:1780704353
Name:CALIFORNIA PACIFIC VASCULAR LABORATORY MEDICAL ASSOCIATE
Entity type:Organization
Organization Name:CALIFORNIA PACIFIC VASCULAR LABORATORY MEDICAL ASSOCIATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-221-7056
Mailing Address - Street 1:3838 CALIFORNIA ST
Mailing Address - Street 2:SUITE 612
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1522
Mailing Address - Country:US
Mailing Address - Phone:415-221-7056
Mailing Address - Fax:415-221-7058
Practice Address - Street 1:3838 CALIFORNIA ST
Practice Address - Street 2:SUITE 612
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1522
Practice Address - Country:US
Practice Address - Phone:415-221-7056
Practice Address - Fax:415-221-7058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ42476ZOtherBCBS
CAZZZ42476ZMedicare PIN