Provider Demographics
NPI:1790711562
Name:SIERRA SAN ANTONIO MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SIERRA SAN ANTONIO MEDICAL CORPORATION
Other - Org Name:SIERRA SAN ANTONIO URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BAJOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-434-1150
Mailing Address - Street 1:16465 SIERRA LAKES PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336
Mailing Address - Country:US
Mailing Address - Phone:909-434-1150
Mailing Address - Fax:909-434-1166
Practice Address - Street 1:16465 SIERRA LAKES PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336
Practice Address - Country:US
Practice Address - Phone:909-434-1150
Practice Address - Fax:909-434-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06908ZMedicare PIN