Healthcare Provider Details

I. General information

NPI: 1043368210
Provider Name (Legal Business Name): LYN MARISE DOS SANTOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MOWRY AVE
FREMONT CA
94538-1716
US

IV. Provider business mailing address

2000 MOWRY AVE
FREMONT CA
94538-1716
US

V. Phone/Fax

Practice location:
  • Phone: 510-795-2002
  • Fax:
Mailing address:
  • Phone: 510-795-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC50666
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: