Healthcare Provider Details

I. General information

NPI: 1013424217
Provider Name (Legal Business Name): BAY AREA PEDIATRIC PRIMARY CARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 N JACKSON AVE STE 203
SAN JOSE CA
95116-1604
US

IV. Provider business mailing address

244 N JACKSON AVE STE 203
SAN JOSE CA
95116-1604
US

V. Phone/Fax

Practice location:
  • Phone: 408-729-0701
  • Fax: 408-729-5085
Mailing address:
  • Phone: 408-729-0701
  • Fax: 408-729-5085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA105688
License Number StateCA

VIII. Authorized Official

Name: JERRY MERCADO
Title or Position: CEO
Credential: MD
Phone: 408-729-0701