Provider Demographics
NPI:1871582155
Name:WALNUT CREEK MEDICAL GROUP
Entity type:Organization
Organization Name:WALNUT CREEK MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MAEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'REGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-947-0417
Mailing Address - Street 1:2621 SHADELANDS DRIVE
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598
Mailing Address - Country:US
Mailing Address - Phone:925-947-0417
Mailing Address - Fax:925-947-4379
Practice Address - Street 1:2621 SHADELANDS DRIVE
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598
Practice Address - Country:US
Practice Address - Phone:925-947-0417
Practice Address - Fax:925-947-4379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42383207Q00000X
CAA42969207Q00000X
CAG370050207Q00000X
CAA55743207R00000X
CAA50662207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G37005Medicare UPIN
A50662Medicare UPIN
CA00A506620Medicare ID - Type Unspecified
CA00A557430Medicare ID - Type Unspecified
00G423830Medicare ID - Type Unspecified
CA00G370050Medicare ID - Type Unspecified
CAH66606Medicare UPIN
A42969Medicare UPIN
A55743Medicare UPIN
A48935Medicare UPIN
00A429690Medicare ID - Type Unspecified
CAH49380Medicare UPIN