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General NPI Number Information
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NPI Number | 1679629968
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Entity Type | Organization
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Legal Business Name | CHABOT UROLOGY MEDICAL ASSOCIATES, A PROFESSIONAL CORP.
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Dates
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Enumeration Date | 01/27/2007
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Last Update Date | 07/11/2023
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Provider Practice Location Address
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Address Line | 20055 LAKE CHABOT RD STE 310
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City | CASTRO VALLEY
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State | CA
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Zip | 94546-5334
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Country | US
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Telephone | 510-889-9166
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Fax |
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Provider Business Mailing Address
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Address Line | 20055 LAKE CHABOT RD STE 310
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City | CASTRO VALLEY
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State | CA
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Zip | 94546-5334
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Country | US
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Telephone | 510-889-9166
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SOURJYA PRAKASH MISRA
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Credential | M.D.
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Telephone | 510-889-9166
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | A49141
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License Number State | CA
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