Healthcare Provider Details

I. General information

NPI: 1144370966
Provider Name (Legal Business Name): EDWIN T. BANGI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7373 WEST LN
STOCKTON CA
95210-3377
US

IV. Provider business mailing address

1800 HARRISON ST FL 7
OAKLAND CA
94612-3466
US

V. Phone/Fax

Practice location:
  • Phone: 209-476-2080
  • Fax:
Mailing address:
  • Phone: 510-625-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA86633
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: