Healthcare Provider Details

I. General information

NPI: 1487393419
Provider Name (Legal Business Name): SAMANEH BOLOURCHI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E 31ST ST
OAKLAND CA
94602-1018
US

IV. Provider business mailing address

1411 E 31ST ST
OAKLAND CA
94602-1018
US

V. Phone/Fax

Practice location:
  • Phone: 510-915-0079
  • Fax: 510-535-7313
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A25380
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: