Healthcare Provider Details

I. General information

NPI: 1104944750
Provider Name (Legal Business Name): MANUEL R PANTIGA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OAK ST
SAN JOSE CA
95110-2817
US

IV. Provider business mailing address

5671 SANTA TERESA BLVD SUITE 105
SAN JOSE CA
95123-6512
US

V. Phone/Fax

Practice location:
  • Phone: 408-295-0980
  • Fax: 408-993-9833
Mailing address:
  • Phone: 408-284-2282
  • Fax: 408-754-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberA38847
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: