Provider Demographics
NPI:1073699609
Name:SAN JOSE MEDICAL MANAGEMENT, INC.
Entity Type:Organization
Organization Name:SAN JOSE MEDICAL MANAGEMENT, INC.
Other - Org Name:SAN JOSE MEDICAL GROUP ENDOSCOPY SUITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNIE
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:WALLERSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-278-3015
Mailing Address - Street 1:400 RACE ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3518
Mailing Address - Country:US
Mailing Address - Phone:408-278-3121
Mailing Address - Fax:408-278-3194
Practice Address - Street 1:2585 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4107
Practice Address - Country:US
Practice Address - Phone:408-357-1020
Practice Address - Fax:408-357-1298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ14615ZMedicare ID - Type Unspecified