Healthcare Provider Details

I. General information

NPI: 1073580320
Provider Name (Legal Business Name): TAMALPAIS PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 BON AIR ROAD STE. 105
LARKSPUR CA
94939
US

IV. Provider business mailing address

5 BON AIR ROAD STE. 105
LARKSPUR CA
94939
US

V. Phone/Fax

Practice location:
  • Phone: 415-461-0440
  • Fax: 415-461-3792
Mailing address:
  • Phone: 415-461-0440
  • Fax: 415-461-3792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NELSON BRANCO
Title or Position: CORPORATE PRESIDENT
Credential: MD
Phone: 415-461-0440