Healthcare Provider Details

I. General information

NPI: 1770809154
Provider Name (Legal Business Name): STANLEY RAY VANCE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2010
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W MACARTHUR BLVD
OAKLAND CA
94611-5641
US

IV. Provider business mailing address

275 W MACARTHUR BLVD
OAKLAND CA
94611-5641
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-7813
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA118709
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: