Provider Demographics
NPI:1093819724
Name:RICHARD J TREVINO MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RICHARD J TREVINO MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-926-5300
Mailing Address - Street 1:227 N JACKSON AVE STE 235
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1603
Mailing Address - Country:US
Mailing Address - Phone:408-926-5300
Mailing Address - Fax:408-926-5395
Practice Address - Street 1:227 N JACKSON AVE STE I-205
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1603
Practice Address - Country:US
Practice Address - Phone:408-926-5300
Practice Address - Fax:408-926-5395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29426207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C29460Medicaid
CA00C29460Medicaid