Healthcare Provider Details

I. General information

NPI: 1619072923
Provider Name (Legal Business Name): EAST BAY VASCULAR MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 LA CASA VIA STE 201 BLDG 1
WALNUT CREEK CA
94598
US

IV. Provider business mailing address

130 LA CASA VIA STE 201 BLDG 1
WALNUT CREEK CA
94598
US

V. Phone/Fax

Practice location:
  • Phone: 925-932-5313
  • Fax:
Mailing address:
  • Phone: 925-932-5313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: NANCI CARTER WEBB
Title or Position: PRACTICE MANAGER
Credential:
Phone: 510-832-6131