Healthcare Provider Details

I. General information

NPI: 1780876193
Provider Name (Legal Business Name): EILEEN LUHA SICANGCO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 W EATON AVE
TRACY CA
95376-3420
US

IV. Provider business mailing address

600 COFFEE RD
MODESTO CA
95355-4201
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-1211
  • Fax:
Mailing address:
  • Phone: 209-521-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101244121
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC151916
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: