Healthcare Provider Details

I. General information

NPI: 1881990513
Provider Name (Legal Business Name): HURST OSTEOPATHIC MEDICINE, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2011
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 W 11TH ST SUITE 119
TRACY CA
95376-3856
US

IV. Provider business mailing address

632 W 11TH ST SUITE 119
TRACY CA
95376-3856
US

V. Phone/Fax

Practice location:
  • Phone: 209-832-5500
  • Fax: 209-832-5505
Mailing address:
  • Phone: 209-832-5500
  • Fax: 209-832-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A8081
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A8081
License Number StateCA

VIII. Authorized Official

Name: MICHAEL D HURST
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 209-832-5500