Healthcare Provider Details

I. General information

NPI: 1386308880
Provider Name (Legal Business Name): TEFLON SEMERE AMANIEL NON EMERGENCY MEDICA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2021
Last Update Date: 10/30/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5110 TELEGRAPH AVE UNIT 628
OAKLAND CA
94609-1982
US

IV. Provider business mailing address

5110 TELEGRAPH AVE UNIT 628
OAKLAND CA
94609-1982
US

V. Phone/Fax

Practice location:
  • Phone: 310-484-9070
  • Fax: 510-345-2021
Mailing address:
  • Phone: 310-484-9070
  • Fax: 510-345-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberF2547292
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: