Provider Demographics
NPI:1407129018
Name:CHAVEZ MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:CHAVEZ MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-840-0066
Mailing Address - Street 1:5260 N PALM AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-2217
Mailing Address - Country:US
Mailing Address - Phone:559-840-0066
Mailing Address - Fax:559-272-0479
Practice Address - Street 1:5260 N PALM AVE STE 201
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-2217
Practice Address - Country:US
Practice Address - Phone:559-840-0066
Practice Address - Fax:559-272-0479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-13
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67620207R00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A676201Medicaid
CA00A676201Medicare PIN