Healthcare Provider Details

I. General information

NPI: 1447510789
Provider Name (Legal Business Name): PRESTIGE MED INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11030 BOLLINGER CANYON RD STE 240
SAN RAMON CA
94582-4874
US

IV. Provider business mailing address

PO BOX 3888
SAN RAMON CA
94583-8888
US

V. Phone/Fax

Practice location:
  • Phone: 925-718-6622
  • Fax: 201-690-8632
Mailing address:
  • Phone: 925-718-6622
  • Fax: 201-690-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA80856
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA80856
License Number StateCA

VIII. Authorized Official

Name: DR. JOSEPH Y MARDANZAI
Title or Position: OWNER
Credential: MD
Phone: 925-718-6622