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Organization
MISSION PEAK ORTHOPAEDIC MEDICAL GROUP INC.
Active
Organization
MISSION PEAK ORTHOPAEDIC MEDICAL GROUP INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LINGAGOUD MEMULA (ADMINISTRATOR)
(510) 818-2011
Entity
Organization
Contact information
Practice address
27206 CALAROGA AVE, SUITE 107, HAYWARD, CA 94545-4300
(510) 300-9898
(510) 797-5184
Mailing address
39350 CIVIC CENTER DR STE 300, FREMONT, CA 94538-2331
(510) 797-3933
(510) 797-5184
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
—
NULL
207X00000X
Orthopaedic Surgery Physician
Primary
—
—
208100000X
Physical Medicine & Rehabilitation Physician
—
NULL
208100000X
Physical Medicine & Rehabilitation Physician
—
—
213ES0103X
Foot & Ankle Surgery Podiatrist
—
NULL
213ES0103X
Foot & Ankle Surgery Podiatrist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
ZZZ5427Z
BLUE SHIELD
CA
Enumeration date
08/01/2012
Last updated
12/23/2013
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