Provider Demographics
NPI:1124202296
Name:MEDISINA SA FAMILIA, PA, MD
Entity Type:Organization
Organization Name:MEDISINA SA FAMILIA, PA, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESITA
Authorized Official - Middle Name:YEE
Authorized Official - Last Name:DEGAMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-580-6479
Mailing Address - Street 1:PO BOX 5607
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94083-5607
Mailing Address - Country:US
Mailing Address - Phone:650-580-6479
Mailing Address - Fax:650-735-5580
Practice Address - Street 1:1850 SULLIVAN AVE STE 510
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2230
Practice Address - Country:US
Practice Address - Phone:650-580-6479
Practice Address - Fax:650-735-5580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50610261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#ED965AOtherMEDICARE PTAN
CA#ED965AOtherMEDICARE PTAN