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General NPI Number Information
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NPI Number | 1609888593
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Entity Type | Organization
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Legal Business Name | MISSION PEAK ORTHOPAEDIC MEDICAL GROUP, INC
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Dates
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Enumeration Date | 08/12/2006
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Last Update Date | 08/26/2015
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Provider Practice Location Address
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Address Line | 39350 CIVIC CENTER DR STE 300
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City | FREMONT
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State | CA
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Zip | 94538-2331
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Country | US
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Telephone | 510-797-3933
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Fax | 510-797-5184
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Provider Business Mailing Address
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Address Line | 39350 CIVIC CENTER DR STE 300
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City | FREMONT
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State | CA
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Zip | 94538-2331
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Country | US
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Telephone | 510-797-3933
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Fax | 510-797-5184
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | LINGAGOUD MEMULA
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Credential |
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Telephone | 510-818-2011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | A698780
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | A81391
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | A81391
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA17256
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA17256
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | A657720
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License Number State | CA
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