Basic Information
| Provider Information | |||||||||
| NPI: | 1356330203 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGENTS OF THE UNIV OF CA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | REGENTS UCDPBG NEUROLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 BROADWAY | ||||||||
| Address2: | STE 2600 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958201532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167349200 | ||||||||
| FaxNumber: | 9167349661 | ||||||||
| Practice Location | |||||||||
| Address1: | 4860 Y ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167343588 | ||||||||
| FaxNumber: | 9164522739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIRK | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 9167341166 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | GR002104E | 05 | CA | MEDICAID | ZZZP5701Z | 01 | CA | MEDICAID/CHDP PIN | OTHER | CN4400 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | GPS000040 | 05 | CA | MEDICAID | CI4127 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | DE7275 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | CN4844 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | CR0028 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | DA4168 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | GNP000070 | 05 | CA | MEDICAID |