Healthcare Provider Details

I. General information

NPI: 1922010487
Provider Name (Legal Business Name): RICHARD L WACHT MD MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 30TH ST
OAKLAND CA
94609-3303
US

IV. Provider business mailing address

419 30TH ST
OAKLAND CA
94609-3303
US

V. Phone/Fax

Practice location:
  • Phone: 510-444-4305
  • Fax: 510-444-6356
Mailing address:
  • Phone: 510-444-4305
  • Fax: 510-444-6356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA021202
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA021202
License Number StateCA

VIII. Authorized Official

Name: DR. RICHARD LEE WACHT
Title or Position: OWNER
Credential: MD
Phone: 510-444-4305