Healthcare Provider Details

I. General information

NPI: 1114107935
Provider Name (Legal Business Name): POWELL O. JOSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 F STREET #117
SACRAMENTO CA
95819
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD SUITE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 916-733-1788
  • Fax: 916-733-1787
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA101413
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036122651
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA101413
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: