Provider Demographics
NPI:1649451493
Name:CLINICA MEDICA PEDIATRICA INC
Entity type:Organization
Organization Name:CLINICA MEDICA PEDIATRICA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:E
Authorized Official - Last Name:EYZAGUIRRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-264-2591
Mailing Address - Street 1:3802 NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-3223
Mailing Address - Country:US
Mailing Address - Phone:619-264-2591
Mailing Address - Fax:
Practice Address - Street 1:3802 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-3223
Practice Address - Country:US
Practice Address - Phone:619-264-2591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA425722080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A425720Medicaid
CA00A425720Medicaid