Healthcare Provider Details

I. General information

NPI: 1326585449
Provider Name (Legal Business Name): GOLDEN GATE UROLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 REGENT ST SUITE 612 & 626
BERKELEY CA
94705-2190
US

IV. Provider business mailing address

2999 REGENT ST SUITE 612
BERKELEY CA
94705-2190
US

V. Phone/Fax

Practice location:
  • Phone: 510-495-3332
  • Fax: 510-848-8224
Mailing address:
  • Phone: 510-495-3332
  • Fax: 510-848-8224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberA71078
License Number StateCA

VIII. Authorized Official

Name: SARA BETANCOURT
Title or Position: VP, FINANCE AND ADMINISTRATION
Credential:
Phone: 415-543-2812