Provider Demographics
NPI:1457534968
Name:SAN JOSE STATE UNIVERSITY STUDENT HEALTH CENTER
Entity Type:Organization
Organization Name:SAN JOSE STATE UNIVERSITY STUDENT HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL CHIEF OF STAFF
Authorized Official - Prefix:DR
Authorized Official - First Name:CECILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANIBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-924-6140
Mailing Address - Street 1:1 WASHINGTON SQ
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95192-0037
Mailing Address - Country:US
Mailing Address - Phone:408-924-6120
Mailing Address - Fax:408-924-7786
Practice Address - Street 1:1 WASHINGTON SQ
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95192-0037
Practice Address - Country:US
Practice Address - Phone:408-924-6120
Practice Address - Fax:408-924-7786
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALIFORNIA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0051700OtherMEDI-CAL PROVIDER NUMBER