Healthcare Provider Details

I. General information

NPI: 1871868562
Provider Name (Legal Business Name): O' CONNOR FAMILY MEDICINE RESIDENCY PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 OCONNOR DR
SAN JOSE CA
95128-1633
US

IV. Provider business mailing address

1383 STORY CT
SAN JOSE CA
95127-4331
US

V. Phone/Fax

Practice location:
  • Phone: 408-283-7676
  • Fax:
Mailing address:
  • Phone: 408-458-6661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number20A12161
License Number StateCA

VIII. Authorized Official

Name: DR. ROBERT NORMAN
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 408-283-7676