Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QG0300X | Family Doctor - Geriatric Medicine | 4301062135 | MI |
NPI | 1245238922 |
---|---|
Provider Name | Safwan Kazmouz |
First Address | Tiburon, CA 94920-2180 |
Second Address | Tiburon, CA 94920-2180 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2005 |
Last Update Date | 08/09/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0808272492 | BLUE CROSS BLUE SHIELD (01) | MI |
4123626 | (05) | MI |
G74768 | (02) | MI |