=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306918461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANTA CLARA MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2040 FOREST AVE STE 5
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-4816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-241-2900
-----------------------------------------------------
Fax | 408-244-1696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2040 FOREST AVE STE 5
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-4816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-241-2900
-----------------------------------------------------
Fax | 408-244-1696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DHANU KAPOOR
-----------------------------------------------------
Credential | M.D.,
-----------------------------------------------------
Telephone | 408-241-2900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A80435
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------