Provider Demographics
NPI:1205901535
Name:MEDVEDEV, LUBA (DC)
Entity type:Individual
Prefix:
First Name:LUBA
Middle Name:
Last Name:MEDVEDEV
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4927 ENGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129-4232
Mailing Address - Country:US
Mailing Address - Phone:408-725-2691
Mailing Address - Fax:408-725-0172
Practice Address - Street 1:1 BAYWOOD AVE STE 4
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-1537
Practice Address - Country:US
Practice Address - Phone:650-343-8512
Practice Address - Fax:408-725-0172
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26445111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0264451Medicaid
CADC0264450Medicare ID - Type Unspecified
CADC0264451Medicaid