Healthcare Provider Details

I. General information

NPI: 1740749647
Provider Name (Legal Business Name): MARITESS RAZO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 SHELLGATE CT
HAYWARD CA
94545-1187
US

IV. Provider business mailing address

1411 E 31ST ST
OAKLAND CA
94602-1018
US

V. Phone/Fax

Practice location:
  • Phone: 510-305-8464
  • Fax:
Mailing address:
  • Phone: 510-437-8498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License Number749646
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: