Provider Demographics
NPI:1578858502
Name:LIZARRAGA, BERTHA TIRADO
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:TIRADO
Last Name:LIZARRAGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 ZANKER RD
Mailing Address - Street 2:101
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-2130
Mailing Address - Country:US
Mailing Address - Phone:408-325-5219
Mailing Address - Fax:408-944-0468
Practice Address - Street 1:2625 ZANKER RD
Practice Address - Street 2:101
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-2130
Practice Address - Country:US
Practice Address - Phone:408-325-5219
Practice Address - Fax:408-944-0468
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA009005171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA009005OtherFDC CREDENTIALS
CA000Other000
CA41528OtherUNICARE