Healthcare Provider Details

I. General information

NPI: 1245223932
Provider Name (Legal Business Name): AIBAR HERBERTO HUATUCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 BESSIE AVE SUITE 102
TRACY CA
95376-3080
US

IV. Provider business mailing address

1530 BESSIE AVE SUITE 102
TRACY CA
95376-3080
US

V. Phone/Fax

Practice location:
  • Phone: 209-836-1627
  • Fax: 209-836-5478
Mailing address:
  • Phone: 209-836-1627
  • Fax: 209-836-5478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA32630
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: