=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659626257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF CALIFORNIA SFGH MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2012
-----------------------------------------------------
Last Update Date | 12/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 POTRERO AVE BLDG.5, RM 5H24
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94110-3518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-206-4980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 743749 LOS ANGELES CA 90074-3749
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90074-3749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-514-3000
-----------------------------------------------------
Fax | 415-502-8175
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | JUANITA VILLANUEVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-514-2574
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------