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Individual
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Active
Individual
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Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DO
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
DO21851
OR
208M00000X
Hospitalist Physician
Primary
20A9726
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110186783
RR MEDICARE PTAN NUMBER
OR
05
—
134037
—
OR
01
—
1407812365
NBMC GROUP NPI NUMBER
OR
01
—
CD8723
RR MEDICARE GROUP NUMBER
OR
01
—
R0000WFBTV
MEDICARE GROUP PIN NUMBER
OR
Enumeration date
12/12/2005
Last updated
04/19/2018
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