Basic Information
| Provider Information | |||||||||
| NPI: | 1073504403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELLFORT | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N HUMPHREYS ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013136 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20103 LAKE CHABOT RD | ||||||||
| Address2: | |||||||||
| City: | CASTRO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA14504 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 364SE0003X | PA14504 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Emergency |
ID Information
| ID | Type | State | Issuer | Description | OPA145040 | 01 | CA | BLUE SHIELD | OTHER | OPA145040 | 05 | CA | MEDICAID |