Provider Demographics
NPI:1497842561
Name:CHOICE MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:CHOICE MEDICAL CLINIC, INC
Other - Org Name:CHOICE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAPIA VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-995-0102
Mailing Address - Street 1:1834 STONE AVE
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-1306
Mailing Address - Country:US
Mailing Address - Phone:408-995-0102
Mailing Address - Fax:408-995-0190
Practice Address - Street 1:1895 MOWRY AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1737
Practice Address - Country:US
Practice Address - Phone:510-792-3398
Practice Address - Fax:510-792-3951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGR0006545207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0006545Medicaid