Healthcare Provider Details

I. General information

NPI: 1417144486
Provider Name (Legal Business Name): UMAR DOUGLAS B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SILICON VALLEY BLVD
SAN JOSE CA
95138-1858
US

IV. Provider business mailing address

248 GREENDALE WAY APT 3
SAN JOSE CA
95129-1508
US

V. Phone/Fax

Practice location:
  • Phone: 408-284-9010
  • Fax:
Mailing address:
  • Phone: 408-417-2812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: