Healthcare Provider Details

I. General information

NPI: 1639662455
Provider Name (Legal Business Name): SHAKU NAGPAL, MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 FOREST AVE STE 102
SAN JOSE CA
95128
US

IV. Provider business mailing address

28555 MATADERO CREEK LN
LOS ALTOS HILLS CA
94022-2457
US

V. Phone/Fax

Practice location:
  • Phone: 650-996-4123
  • Fax: 650-941-4903
Mailing address:
  • Phone: 650-996-4123
  • Fax: 650-941-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA25652
License Number StateCA

VIII. Authorized Official

Name: SHAKU NAGPAL
Title or Position: OWNER
Credential: MD
Phone: 650-996-4123