Basic Information
| Provider Information | |||||||||
| NPI: | 1881685527 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN RADIATION ONCOLOGY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2165 S BASCOM AVE STE B | ||||||||
| Address2: | |||||||||
| City: | CAMPBELL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950083280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S SAN MATEO DR | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944013805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093422300 | ||||||||
| FaxNumber: | 2095244240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | ORTEGA | ||||||||
| AuthorizedOfficialFirstName: | GUADALUPE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6613229958 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | GR0080592 | 05 | CA | MEDICAID | GR0080593 | 05 | CA | MEDICAID | GR0080590 | 05 | CA | MEDICAID | ZZZ02838Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ02839Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ49854Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ52889Y | 01 | CA | BLUE SHIELD | OTHER |