Healthcare Provider Details

I. General information

NPI: 1235332362
Provider Name (Legal Business Name): JEANNIE URQUICO VISTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANNIE MANGUERA URQUICO M.D.

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 04/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 COYLE AVE STE 310
CARMICHAEL CA
95608-0303
US

IV. Provider business mailing address

6555 COYLE AVE STE 310
CARMICHAEL CA
95608-0303
US

V. Phone/Fax

Practice location:
  • Phone: 916-965-4612
  • Fax:
Mailing address:
  • Phone: 916-965-4612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA100182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: