Healthcare Provider Details

I. General information

NPI: 1780119966
Provider Name (Legal Business Name): NORCAL PEDIATRIC GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 YGNACIO VALLEY RD STE 108
WALNUT CREEK CA
94598-3190
US

IV. Provider business mailing address

8275 ROYALL OAKS DR
GRANITE BAY CA
95746-9340
US

V. Phone/Fax

Practice location:
  • Phone: 925-939-9200
  • Fax: 925-939-9205
Mailing address:
  • Phone: 510-813-4747
  • Fax: 877-992-2989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberC51575
License Number StateCA

VIII. Authorized Official

Name: DR. FADI GEORGE HADDAD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 510-813-4747