=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508869868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIDNEY EVAN WANETICK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19845 LAKE CHABOT RD STE 302
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-4055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-886-3400
-----------------------------------------------------
Fax | 510-886-0861
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 BUTLER DR
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94549-3358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-283-9420
-----------------------------------------------------
Fax | 925-283-6518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | G46693
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------