Healthcare Provider Details

I. General information

NPI: 1821301110
Provider Name (Legal Business Name): JAMES MATTHEW WANTUCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MISSION ST STE 800
SAN FRANCISCO CA
94105-1744
US

IV. Provider business mailing address

650 5TH ST STE 311
SAN FRANCISCO CA
94107-1542
US

V. Phone/Fax

Practice location:
  • Phone: 415-231-5333
  • Fax: 415-231-5332
Mailing address:
  • Phone: 415-231-5333
  • Fax: 415-231-5332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA117984
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA117984
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: