Provider Demographics
NPI:1710366828
Name:DR. QUEEN FAMILY MEDICINE
Entity Type:Organization
Organization Name:DR. QUEEN FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWCER
Authorized Official - Prefix:
Authorized Official - First Name:QUYNH QUEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:408-274-6944
Mailing Address - Street 1:1675 BURDETTE DR STE 20
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121-1667
Mailing Address - Country:US
Mailing Address - Phone:408-274-6944
Mailing Address - Fax:408-274-2258
Practice Address - Street 1:1675 BURDETTE DR STE 20
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1667
Practice Address - Country:US
Practice Address - Phone:408-274-6944
Practice Address - Fax:408-274-2258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8237261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX82370Medicaid
H93930Medicare UPIN