Healthcare Provider Details

I. General information

NPI: 1427326859
Provider Name (Legal Business Name): MONTEREY BAY GASTROENTEROLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 SOQUEL DR SUITE 12
SANTA CRUZ CA
95065-1716
US

IV. Provider business mailing address

1505 SOQUEL DR SUITE 12
SANTA CRUZ CA
95065-1716
US

V. Phone/Fax

Practice location:
  • Phone: 831-713-5050
  • Fax: 831-475-0101
Mailing address:
  • Phone: 831-713-5050
  • Fax: 831-475-0101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. JUSTIN BENNET
Title or Position: VICE-PRESIDENT
Credential: M.D.
Phone: 831-713-5050