Provider Demographics
NPI:1699792598
Name:EAR, NOSE AND THROAT ASSOCIATES OF SAN MATEO COUNTY INC
Entity type:Organization
Organization Name:EAR, NOSE AND THROAT ASSOCIATES OF SAN MATEO COUNTY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:F
Authorized Official - Last Name:BOCK HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-344-6896
Mailing Address - Street 1:100 S. ELLSWORTH AVENUE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3931
Mailing Address - Country:US
Mailing Address - Phone:650-344-6896
Mailing Address - Fax:650-344-2794
Practice Address - Street 1:100 S. ELLSWORTH AVENUE
Practice Address - Street 2:SUITE 308
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3931
Practice Address - Country:US
Practice Address - Phone:650-344-6896
Practice Address - Fax:650-344-2794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Y00000X
CAG71603207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ80557ZOtherBLUE SHIELD
CAZZZ80557ZMedicaid
CAZZZ80557ZOtherBLUE SHIELD