Basic Information
| Provider Information | |||||||||
| NPI: | 1104978840 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN MATEO COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAN MATEO MEDICAL CENTER - WILLOW CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 HARBOR BLVD | ||||||||
| Address2: | BUILDING C | ||||||||
| City: | BELMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940024047 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 795 WILLOW RD | ||||||||
| Address2: | BLDG 332 | ||||||||
| City: | MENLO PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940252539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505787190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVILA | ||||||||
| AuthorizedOfficialFirstName: | JUDITH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AOD PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6508025057 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 4191 | 01 | CA | PROVIDER NUMBER | OTHER |