Healthcare Provider Details

I. General information

NPI: 1063559698
Provider Name (Legal Business Name): HILLTOP PEDIATRICS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2970 HILLTOP MALL RD SUITE 305
RICHMOND CA
94806-1947
US

IV. Provider business mailing address

2970 HILLTOP MALL RD SUITE 305
RICHMOND CA
94806-1947
US

V. Phone/Fax

Practice location:
  • Phone: 510-222-5437
  • Fax: 510-222-5487
Mailing address:
  • Phone: 510-222-5437
  • Fax: 510-222-5487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberFNP 14657
License Number StateCA

VIII. Authorized Official

Name: DR. MARGERY LACKMAN
Title or Position: CHIEF OPERATING OFFICER
Credential: M.D.
Phone: 510-222-5437