Healthcare Provider Details

I. General information

NPI: 1740210095
Provider Name (Legal Business Name): JACQUELINE MIODOWNIK-AISENBERG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 EL CAMINO REAL
SAN BRUNO CA
94066-3009
US

IV. Provider business mailing address

901 EL CAMINO REAL
SAN BRUNO CA
94066-3009
US

V. Phone/Fax

Practice location:
  • Phone: 650-742-2100
  • Fax: 650-742-1311
Mailing address:
  • Phone: 650-742-2100
  • Fax: 650-742-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC164852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: