Healthcare Provider Details

I. General information

NPI: 1992743579
Provider Name (Legal Business Name): MOLLY DETGEN MAGNANO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 TELEGRAPH AVE 120
BERKELEY CA
94705-1192
US

IV. Provider business mailing address

2850 TELEGRAPH AVE 120
BERKELEY CA
94705-1192
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-8120
  • Fax: 510-649-1238
Mailing address:
  • Phone: 510-204-8120
  • Fax: 510-649-1238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberA80346
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: