Healthcare Provider Details

I. General information

NPI: 1306005244
Provider Name (Legal Business Name): ST. THOMAS MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 HALFORD AVE
SANTA CLARA CA
95051-3205
US

IV. Provider business mailing address

1470 HALFORD AVE
SANTA CLARA CA
95051-3205
US

V. Phone/Fax

Practice location:
  • Phone: 408-260-7575
  • Fax: 408-556-6773
Mailing address:
  • Phone: 408-260-7575
  • Fax: 408-556-6773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA13417
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN CANTWELL
Title or Position: PRESIDENT
Credential: MD
Phone: 408-260-7575