Provider Demographics
NPI:1598441321
Name:MACIAS NUNEZ, JOVITA ERENDIRA
Entity Type:Individual
Prefix:
First Name:JOVITA
Middle Name:ERENDIRA
Last Name:MACIAS NUNEZ
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 1:482 W SAN YSIDRO BLVD APT 259
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-2444
Mailing Address - Country:US
Mailing Address - Phone:619-678-8460
Mailing Address - Fax:
Practice Address - Street 1:AV IGNACIO ALLENDE 7295 LOCAL-9
Practice Address - Street 2:COL. INDEPENDENCIA
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22055
Practice Address - Country:MX
Practice Address - Phone:663-428-8194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
10928347261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental