Provider Demographics
NPI:1104944750
Name:PANTIGA, MANUEL R (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:R
Last Name:PANTIGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5671 SANTA TERESA BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-6512
Mailing Address - Country:US
Mailing Address - Phone:408-284-2282
Mailing Address - Fax:408-754-0450
Practice Address - Street 1:100 OAK ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-2817
Practice Address - Country:US
Practice Address - Phone:408-295-0980
Practice Address - Fax:408-993-9833
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38847261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)