Provider Demographics
NPI:1124208202
Name:MADRID, JORGE JULIO (LAC)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:JULIO
Last Name:MADRID
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 SHATTUCK AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2724
Mailing Address - Country:US
Mailing Address - Phone:510-666-8234
Mailing Address - Fax:
Practice Address - Street 1:2550 SHATTUCK AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2724
Practice Address - Country:US
Practice Address - Phone:510-666-8234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 9617171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist