Healthcare Provider Details

I. General information

NPI: 1720212012
Provider Name (Legal Business Name): SUTTER WEST BAY MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 COLBY ST #205
BERKELEY CA
94705-2083
US

IV. Provider business mailing address

PO BOX 254947
SACRAMENTO CA
95865-4947
US

V. Phone/Fax

Practice location:
  • Phone: 510-776-4143
  • Fax: 510-486-1478
Mailing address:
  • Phone: 916-854-6975
  • Fax: 916-854-6844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN GATES
Title or Position: RCFO
Credential:
Phone: 415-600-7755