Healthcare Provider Details

I. General information

NPI: 1457333700
Provider Name (Legal Business Name): JERIC CANDA VILLARUZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 GREEN VALLEY RD
FREEDOM CA
95019-3139
US

IV. Provider business mailing address

268 GREEN VALLEY RD
FREEDOM CA
95019-3139
US

V. Phone/Fax

Practice location:
  • Phone: 831-728-0440
  • Fax: 831-728-4293
Mailing address:
  • Phone: 831-728-0440
  • Fax: 831-728-4293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA54496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: