Organization
PEDIATRIC PSYCHIATRIC MED ASSOC CHO
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISA HARDY MD (HEAD OF DEPT)
(510) 428-3571
Entity
Organization
Contact information
Practice address
747 52ND ST, OAKLAND, CA 94609-1809
(510) 428-3571
(510) 597-7171
Mailing address
3116 W MARCH LN, STE 200, STOCKTON, CA 95219-2369
(209) 473-6555
(209) 473-6543
Taxonomy
Speciality
Code
Description
License number
State
2080P0006X
Developmental - Behavioral Pediatrics Physician
Primary
G77771
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
G77771
DR HARDY'S CA MD LIC
CA
01
—
GR0095840
MEDI-CAL #
CA
Enumeration date
02/27/2007
Last updated
08/22/2020
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