Basic Information
Provider Information | |||||||||
NPI: | 1528245156 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF SANTA CLARA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SCVMC ACUTE CARE MEDI-CAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 751 S BASCOM AVE | ||||||||
Address2: |   | ||||||||
City: | SAN JOSE | ||||||||
State: | CA | ||||||||
PostalCode: | 951282604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4088855000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 751 S BASCOM AVE | ||||||||
Address2: |   | ||||||||
City: | SAN JOSE | ||||||||
State: | CA | ||||||||
PostalCode: | 951282604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4088855000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2008 | ||||||||
LastUpdateDate: | 01/25/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BANUELOS | ||||||||
AuthorizedOfficialFirstName: | ALFONSO | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | CMO | ||||||||
AuthorizedOfficialTelephone: | 4088850000 | ||||||||
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 | 282N00000X |   | CA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | ZZR00038W | 05 | CA |   | MEDICAID |