Healthcare Provider Details

I. General information

NPI: 1003289919
Provider Name (Legal Business Name): EAST BAY GYNECOLOGIC ONCOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MONTE VISTA RD
ORINDA CA
94563-1619
US

IV. Provider business mailing address

105 MONTE VISTA RD
ORINDA CA
94563-1619
US

V. Phone/Fax

Practice location:
  • Phone: 310-926-2451
  • Fax:
Mailing address:
  • Phone: 310-926-2451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberA92223
License Number StateCA

VIII. Authorized Official

Name: DR. DIMITRY LERNER
Title or Position: OWNER
Credential: MD
Phone: 310-926-2451