Basic Information
| Provider Information | |||||||||
| NPI: | 1386654945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLANON | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 E 31ST STREET | ||||||||
| Address2: | OAKCARE MEDICAL GROUP | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946021080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104374323 | ||||||||
| FaxNumber: | 5104375042 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 E 31ST STREET | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946021080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104374323 | ||||||||
| FaxNumber: | 5104375042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 02/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | G56122 | CA | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 00G56122 | 05 | CA | MEDICAID |