Healthcare Provider Details

I. General information

NPI: 1134973951
Provider Name (Legal Business Name): AJMAL ESAAQ ESAAQ POR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 ROLAND WAY STE 100
OAKLAND CA
94621-2034
US

IV. Provider business mailing address

8501 BRUCEVILLE RD APT 260
ELK GROVE CA
95758-7267
US

V. Phone/Fax

Practice location:
  • Phone: 916-580-7208
  • Fax:
Mailing address:
  • Phone: 916-580-7208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: