Provider Demographics
NPI:1447354964
Name:PAUL WOTOWIC A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PAUL WOTOWIC A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOTOWIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-866-6778
Mailing Address - Street 1:5201 NORRIS CANYON RD STE 330
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-5405
Mailing Address - Country:US
Mailing Address - Phone:925-866-6778
Mailing Address - Fax:925-866-2902
Practice Address - Street 1:5201 NORRIS CANYON RD STE 330
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5405
Practice Address - Country:US
Practice Address - Phone:925-866-6778
Practice Address - Fax:925-866-2902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42036208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE32513Medicare UPIN
CAZZZ06485ZMedicare PIN