Provider Demographics
NPI:1952356909
Name:SAN JOAQUIN HEMATOLOGY ONCOLOGY
Entity Type:Organization
Organization Name:SAN JOAQUIN HEMATOLOGY ONCOLOGY
Other - Org Name:NEELESH S BANGALORE MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:INMAN
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:GABRIELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-474-1458
Mailing Address - Street 1:PO BOX 7667
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:SUITE B260
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-474-1458
Practice Address - Fax:209-474-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA708830332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A708830Medicaid
5618371OtherOTHER ID NUMBER
5618371OtherOTHER ID NUMBER-COMMERCIAL NUMBER