Healthcare Provider Details

I. General information

NPI: 1124561303
Provider Name (Legal Business Name): SOUTH BAY ANGIOGRAPHY AND INTERVENTIONAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 S BASCOM AVE SUITE 200
CAMPBELL CA
95008-7800
US

IV. Provider business mailing address

2255 S BASCOM AVE SUITE 200
CAMPBELL CA
95008-7800
US

V. Phone/Fax

Practice location:
  • Phone: 408-376-3626
  • Fax: 408-871-2377
Mailing address:
  • Phone: 408-376-3626
  • Fax: 408-871-2377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. POLYXENE G KOKINOS
Title or Position: CEO
Credential: M.D.
Phone: 408-376-3626