Provider Demographics
NPI:1699701391
Name:JABER, PHILIP
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:
Last Name:JABER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:PHILIP
Other - Middle Name:
Other - Last Name:JABER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2801 ENCINAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4726
Mailing Address - Country:US
Mailing Address - Phone:510-523-4907
Mailing Address - Fax:510-523-4580
Practice Address - Street 1:2801 ENCINAL AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4726
Practice Address - Country:US
Practice Address - Phone:510-523-4907
Practice Address - Fax:510-523-4580
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA227100Medicaid
CA5466790001Medicare ID - Type Unspecified