Provider Demographics
NPI:1912393224
Name:BACA, AMY (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:415-600-4750
Mailing Address - Fax:415-369-1314
Practice Address - Street 1:45 CASTRO ST STE 402
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-1040
Practice Address - Country:US
Practice Address - Phone:415-600-4750
Practice Address - Fax:415-369-1314
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1165025207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA146447OtherSTATE MEDICAL LICENSE
CAFB6717295OtherFEDERAL DEA LICENSE