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
39350 CIVIC CENTER DR STE 300, FREMONT, CA 94538-2331
(510) 797-3933
(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
A657720
CA
207X00000X
Orthopaedic Surgery Physician
A698780
CA
208100000X
Physical Medicine & Rehabilitation Physician
A81391
CA
2081P2900X
Pain Medicine (Physical Medicine & Rehabilitation) Physician
A81391
CA
363A00000X
Physician Assistant
PA17256
CA
363AS0400X
Surgical Physician Assistant
PA17256
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
ZZZ5427Z
BLUE SHIELD
CA
Enumeration date
08/12/2006
Last updated
08/26/2015
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