Healthcare Provider Details

I. General information

NPI: 1912938085
Provider Name (Legal Business Name): ARMANDO V DEPALA JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 A PROFESSIONAL DRIVE
PETALUMA CA
94954
US

IV. Provider business mailing address

1550 A PROFESSIONAL DRIVE
PETALUMA CA
94954
US

V. Phone/Fax

Practice location:
  • Phone: 707-769-7403
  • Fax: 707-769-0134
Mailing address:
  • Phone: 707-769-7403
  • Fax: 707-769-0134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA52324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: