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General NPI Number Information
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NPI Number | 1154326262
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Entity Type | Individual
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Provider Name | NEELESH S BANGALORE MD, PHD
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Gender | Male
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Dates
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Enumeration Date | 06/15/2005
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Last Update Date | 06/25/2012
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Provider Practice Location Address
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Address Line | 4600 S TRACY BLVD STE 108
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City | TRACY
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State | CA
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Zip | 95377-8105
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Country | US
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Telephone | 209-839-9115
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Fax | 209-833-7262
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Provider Business Mailing Address
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Address Line | PO BOX 7667
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City | STOCKTON
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State | CA
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Zip | 95267-0667
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Country | US
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Telephone | 209-839-9115
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Fax | 209-833-7262
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A70883
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License Number State | CA
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