Provider Demographics
NPI:1437170354
Name:ANGEL M. SAN JOSE, M.D., P.C.
Entity Type:Organization
Organization Name:ANGEL M. SAN JOSE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:SAN JOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-935-1168
Mailing Address - Street 1:RR 5 BOX 20
Mailing Address - Street 2:SUITE 207
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-9611
Mailing Address - Country:US
Mailing Address - Phone:276-935-1168
Mailing Address - Fax:276-935-1343
Practice Address - Street 1:RR 5 BOX 20
Practice Address - Street 2:SUITE 207
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-9611
Practice Address - Country:US
Practice Address - Phone:276-935-1168
Practice Address - Fax:276-935-1343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238113208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64113434Medicaid
VA187487OtherANTHEM BLUE CROSS BLUE SH
WV3810003447Medicaid
VA00W564A01Medicare ID - Type Unspecified
VA187487OtherANTHEM BLUE CROSS BLUE SH