=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306997721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN HUNNICUTT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 CASTRO RD
-----------------------------------------------------
City | SAN PABLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94806-3164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-970-3237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 CASTRO RD
-----------------------------------------------------
City | SAN PABLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94806-3164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0105X
-----------------------------------------------------
Taxonomy Name | Clinical Pathology/Laboratory Medicine Physician
-----------------------------------------------------
License Number | MD-021874
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------