=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861921819
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA GOSS CALMAN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2017
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1365 BUENA VISTA RD
-----------------------------------------------------
City | MONTARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94037-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-728-1802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 371527
-----------------------------------------------------
City | MONTARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94037-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-728-1802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD00028791
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------