Healthcare Provider Details

I. General information

NPI: 1386627750
Provider Name (Legal Business Name): DIANA BUBANJA PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3718 MACDONALD AVE
RICHMOND CA
94805-2227
US

IV. Provider business mailing address

PO BOX 612260
SAN JOSE CA
95161-2260
US

V. Phone/Fax

Practice location:
  • Phone: 510-965-0811
  • Fax: 510-965-0815
Mailing address:
  • Phone: 877-325-2776
  • Fax: 408-945-4011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT14646
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: