Provider Demographics
NPI:1417271305
Name:CLINICA MEDICA SAN PEDRO OF CALIFORNIA, INC
Entity Type:Organization
Organization Name:CLINICA MEDICA SAN PEDRO OF CALIFORNIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-863-1212
Mailing Address - Street 1:13939 SAN ANTONIO DR
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-4036
Mailing Address - Country:US
Mailing Address - Phone:562-863-1212
Mailing Address - Fax:562-864-1212
Practice Address - Street 1:13939 SAN ANTONIO DR
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-4036
Practice Address - Country:US
Practice Address - Phone:562-863-1212
Practice Address - Fax:562-864-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-21
Last Update Date:2010-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39722207V00000X
CAA76805208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty