Basic Information
| Provider Information | |||||||||
| NPI: | 1104944750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANTIGA | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5671 SANTA TERESA BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951236512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082842282 | ||||||||
| FaxNumber: | 4087540450 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 OAK ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951102817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082950980 | ||||||||
| FaxNumber: | 4089939833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 12/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | A38847 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.