Provider Demographics
NPI:1376909085
Name:MEDINA, ERNESTO (DC)
Entity Type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:
Last Name:MEDINA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 S WINCHESTER BLVD
Mailing Address - Street 2:SUITE J218
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3901
Mailing Address - Country:US
Mailing Address - Phone:408-290-6236
Mailing Address - Fax:
Practice Address - Street 1:1101 S WINCHESTER BLVD
Practice Address - Street 2:SUITE J218
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3901
Practice Address - Country:US
Practice Address - Phone:408-290-6236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-11
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 32520111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor