Provider Demographics
NPI:1093809139
Name:PRISMA CARE, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PRISMA CARE, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-575-5000
Mailing Address - Street 1:2648 MAIN ST
Mailing Address - Street 2:SUITE #A
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-4664
Mailing Address - Country:US
Mailing Address - Phone:619-575-5000
Mailing Address - Fax:619-575-5060
Practice Address - Street 1:2648 MAIN ST
Practice Address - Street 2:SUITE #A
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-4664
Practice Address - Country:US
Practice Address - Phone:619-575-5000
Practice Address - Fax:619-575-5060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A433010Medicaid
W15902Medicare ID - Type Unspecified