Basic Information
| Provider Information | |||||||||
| NPI: | 1487785531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CYPRESS WOMENS CANCER TREATMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1455 MONTEGO | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256273440 | ||||||||
| FaxNumber: | 9256273450 | ||||||||
| Practice Location | |||||||||
| Address1: | 1455 MONTEGO | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256273440 | ||||||||
| FaxNumber: | 9256273450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | EDRAKI | ||||||||
| AuthorizedOfficialFirstName: | BABAK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9256273440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | G67092 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207V00000X | G67092 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1487785531 | 05 | CA | MEDICAID |