Healthcare Provider Details

I. General information

NPI: 1861591752
Provider Name (Legal Business Name): INTERNATIONAL PEDIATRIC MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 INTERNATIONAL BLVD #102
OAKLAND CA
94606
US

IV. Provider business mailing address

600 INTERNATIONAL BLVD #102
OAKLAND CA
94606
US

V. Phone/Fax

Practice location:
  • Phone: 510-208-3540
  • Fax: 510-208-3553
Mailing address:
  • Phone: 510-208-3540
  • Fax: 510-208-3553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA67904
License Number StateCA

VIII. Authorized Official

Name: AN TAN PHAM
Title or Position: MD
Credential: MD
Phone: 510-208-3540