Healthcare Provider Details

I. General information

NPI: 1760549141
Provider Name (Legal Business Name): PEDIATRIC HEMATOLOGY ONCOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

5528 PACHECO BLVD #A
PACHECO CA
94553-5126
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3885
  • Fax:
Mailing address:
  • Phone: 925-363-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberZZZ77127Z
License Number StateCA

VIII. Authorized Official

Name: ELLIOTT VICHINSKY
Title or Position: PARTNER
Credential: M.D.
Phone: 510-428-3855