Provider Demographics
NPI:1356399919
Name:MEDINA, CELERINA DE BORJA
Entity type:Individual
Prefix:DR
First Name:CELERINA
Middle Name:DE BORJA
Last Name:MEDINA
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 1:4149 TWEEDY BOULEVARD
Mailing Address - Street 2:STE B
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-6167
Mailing Address - Country:US
Mailing Address - Phone:323-564-4545
Mailing Address - Fax:323-564-3063
Practice Address - Street 1:4149 TWEEDY BOULEVARD
Practice Address - Street 2:STE B
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6167
Practice Address - Country:US
Practice Address - Phone:323-564-4545
Practice Address - Fax:323-564-3063
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45547208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A455470Medicaid
CA3258223Medicare ID - Type Unspecified
CA00A455470Medicaid