Provider Demographics
NPI:1538241252
Name:SAN BRUNO PEDIATRICS INC
Entity type:Organization
Organization Name:SAN BRUNO PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:ABUNTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-873-4545
Mailing Address - Street 1:5528 PACHECO BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:PACHECO
Mailing Address - State:CA
Mailing Address - Zip Code:94553
Mailing Address - Country:US
Mailing Address - Phone:925-363-8170
Mailing Address - Fax:925-363-4995
Practice Address - Street 1:1001 SNEATH LANE
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066
Practice Address - Country:US
Practice Address - Phone:650-873-4545
Practice Address - Fax:650-873-4544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80451208000000X
CAA60694208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1538241252Medicaid