Basic Information
| Provider Information | |||||||||
| NPI: | 1114180635 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER CAARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3671 BUSINESS DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958202165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167346637 | ||||||||
| FaxNumber: | 9167344150 | ||||||||
| Practice Location | |||||||||
| Address1: | 3671 BUSINESS DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958202165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167346637 | ||||||||
| FaxNumber: | 9167344150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VARGAS | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | C.H.P. ASSISTANT CHIEF | ||||||||
| AuthorizedOfficialTelephone: | 9167346637 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | CN4400 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | DE7275 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | GPS000040 | 05 | CA | MEDICAID | ZZZP5701Z | 01 | CA | MEDICAID/CHDP PIN | OTHER | CI4127 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | DA4168 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | GR002104M | 05 | CA | MEDICAID | CR0028 | 01 | CA | RAILROAD MEDICARE PIN | OTHER | GNP000070 | 05 | CA | MEDICAID | CN4844 | 01 | CA | RAILROAD MEDICARE PIN | OTHER |