Basic Information
| Provider Information | |||||||||
| NPI: | 1104014935 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF SANTA CLARA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SCVMC PHYSICIAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5730 | ||||||||
| Address2: | PATIENT BUSINESS SERVICES | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951505730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088857200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 751 S BASCOM AVE | ||||||||
| Address2: | PHYSICIAN SERVICES | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951282604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088855000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 10/05/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BANUELOS | ||||||||
| AuthorizedOfficialFirstName: | ALFONSO | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 40888550000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF SANTA CLARA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy |
ID Information
| ID | Type | State | Issuer | Description | GR0076271 | 05 | CA | MEDICAID | GR0076270 | 05 | CA | MEDICAID | GR0076272 | 05 | CA | MEDICAID |