Basic Information
| Provider Information | |||||||||
| NPI: | 1851470959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAGIMBI | ||||||||
| FirstName: | ATHANASIOS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1530 BESSIE AVE | ||||||||
| Address2: | STE 105 | ||||||||
| City: | TRACY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953763080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094676866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1530 BESSIE AVE | ||||||||
| Address2: | STE 105 | ||||||||
| City: | TRACY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953763080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098322095 | ||||||||
| FaxNumber: | 2098327828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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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 | 207LP2900X | A76322 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A763220 | 05 | CA | MEDICAID |