Provider Demographics
NPI:1861011389
Name:MOBILE MED MD INC
Entity Type:Organization
Organization Name:MOBILE MED MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HIPOLITO
Authorized Official - Middle Name:GALLARDO
Authorized Official - Last Name:MARIANO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:559-330-7904
Mailing Address - Street 1:5454 E NEES AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-9503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5454 E NEES AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-9503
Practice Address - Country:US
Practice Address - Phone:559-330-7904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1144451659Medicaid