Healthcare Provider Details

I. General information

NPI: 1699744383
Provider Name (Legal Business Name): SAN JOAQUIN HEMATOLOGY/ONCOLOGY, A PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 S TRACY BLVD STE 108
TRACY CA
95377-8105
US

IV. Provider business mailing address

PO BOX 7667
STOCKTON CA
95267-0667
US

V. Phone/Fax

Practice location:
  • Phone: 209-839-9115
  • Fax:
Mailing address:
  • Phone: 209-477-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA70883
License Number StateCA

VIII. Authorized Official

Name: DR. NEELESH S BANGALORE
Title or Position: CEO
Credential: MD, PHD
Phone: 209-477-2000