1548328974 NPI number — GLORIA PEDRUCO NP

Table of content: GLORIA PEDRUCO NP (NPI 1548328974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548328974 NPI number — GLORIA PEDRUCO NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDRUCO
Provider First Name:
GLORIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548328974
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 W 39TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN MATEO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94403-4364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-573-2222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2710 MIDDLEFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDWOOD CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94063-3404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-364-6010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  RN295606 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RN295606 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".