Healthcare Provider Details

I. General information

NPI: 1538241252
Provider Name (Legal Business Name): SAN BRUNO PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SNEATH LANE SUITE 104
SAN BRUNO CA
94066
US

IV. Provider business mailing address

5528 PACHECO BLVD STE A
PACHECO CA
94553
US

V. Phone/Fax

Practice location:
  • Phone: 650-873-4545
  • Fax: 650-873-4544
Mailing address:
  • Phone: 925-363-8170
  • Fax: 925-363-4995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA80451
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA60694
License Number StateCA

VIII. Authorized Official

Name: MARIA VANESSA ABUNTO
Title or Position: PRESIDENT
Credential: MD
Phone: 650-873-4545