Healthcare Provider Details

I. General information

NPI: 1073504403
Provider Name (Legal Business Name): ERIC S. BELLFORT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20103 LAKE CHABOT RD
CASTRO VALLEY CA
94546
US

IV. Provider business mailing address

1000 N HUMPHREYS ST
FLAGSTAFF AZ
86001-3136
US

V. Phone/Fax

Practice location:
  • Phone: 209-342-2300
  • Fax: 209-524-4240
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14504
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SE0003X
TaxonomyEmergency Clinical Nurse Specialist
License NumberPA14504
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: