Healthcare Provider Details

I. General information

NPI: 1811475759
Provider Name (Legal Business Name): UNIVERSITY OF CALIFORNIA SFGH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVENUE, BLDG 5, ROOM 1N1
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

PO BOX 743749
LOS ANGELES CA
90074-3749
US

V. Phone/Fax

Practice location:
  • Phone: 415-502-0661
  • Fax: 415-476-6206
Mailing address:
  • Phone: 415-514-3000
  • Fax: 415-502-8175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: JUANITA VILLANUEVA
Title or Position: DIRECTOR
Credential:
Phone: 415-514-2574