Healthcare Provider Details

I. General information

NPI: 1053511667
Provider Name (Legal Business Name): NIV E DECALO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2007
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N JACKSON AVE
SAN JOSE CA
95116
US

IV. Provider business mailing address

250 CHERRY LN STE 116
MANTECA CA
95337-4398
US

V. Phone/Fax

Practice location:
  • Phone: 408-259-5000
  • Fax:
Mailing address:
  • Phone: 209-647-2184
  • Fax: 209-647-4684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA120987
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: