Provider Demographics
NPI:1699059113
Name:NANCY J V BOHANNON, MD, MEDICAL CORPORATION
Entity type:Organization
Organization Name:NANCY J V BOHANNON, MD, MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-648-7622
Mailing Address - Street 1:1580 VALENCIA ST
Mailing Address - Street 2:STE 504
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4423
Mailing Address - Country:US
Mailing Address - Phone:415-648-7622
Mailing Address - Fax:415-648-6805
Practice Address - Street 1:1580 VALENCIA ST
Practice Address - Street 2:STE 504
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-4423
Practice Address - Country:US
Practice Address - Phone:415-648-7622
Practice Address - Fax:415-648-6805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25795207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA25795OtherSTATE LICENSE
CA00A257950Medicare PIN
CAF03942Medicare UPIN