Healthcare Provider Details

I. General information

NPI: 1497173892
Provider Name (Legal Business Name): TAKUDZWA MKOROMBINDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 BRUCEVILLE RD
SACRAMENTO CA
95823-4671
US

IV. Provider business mailing address

6600 BRUCEVILLE RD
SACRAMENTO CA
95823-4671
US

V. Phone/Fax

Practice location:
  • Phone: 916-688-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number181748A
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number181748A
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: