Healthcare Provider Details

I. General information

NPI: 1679581425
Provider Name (Legal Business Name): ADDY SQUARER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 S WINCHESTER BLVD
SAN JOSE CA
95128-2930
US

IV. Provider business mailing address

828 S WINCHESTER BLVD
SAN JOSE CA
95128-2930
US

V. Phone/Fax

Practice location:
  • Phone: 408-866-4000
  • Fax: 408-866-3999
Mailing address:
  • Phone: 408-866-4000
  • Fax: 408-866-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberG73060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: