Healthcare Provider Details

I. General information

NPI: 1326394974
Provider Name (Legal Business Name): MISSION PEAK ORTHOPAEDIC MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2012
Last Update Date: 12/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27206 CALAROGA AVE SUITE 107
HAYWARD CA
94545-4300
US

IV. Provider business mailing address

39350 CIVIC CENTER DR STE 300
FREMONT CA
94538-2331
US

V. Phone/Fax

Practice location:
  • Phone: 510-300-9898
  • Fax: 510-797-5184
Mailing address:
  • Phone: 510-797-3933
  • Fax: 510-797-5184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: LINGAGOUD MEMULA
Title or Position: ADMINISTRATOR
Credential:
Phone: 510-818-2011