Healthcare Provider Details

I. General information

NPI: 1972540359
Provider Name (Legal Business Name): LOMA VISTA OBGYN MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2577 SAMARITAN DR 810
SAN JOSE CA
95124-4100
US

IV. Provider business mailing address

2577 SAMARITAN DR 810
SAN JOSE CA
95124-4100
US

V. Phone/Fax

Practice location:
  • Phone: 408-358-1888
  • Fax: 408-356-0877
Mailing address:
  • Phone: 408-358-1888
  • Fax: 408-356-0877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number207V00000X
License Number StateCA

VIII. Authorized Official

Name: DR. ANJALI TATE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 408-358-1888