Healthcare Provider Details

I. General information

NPI: 1871520155
Provider Name (Legal Business Name): MARTHA ALBA MEJIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 SAN CARLOS AVE
SAN CARLOS CA
94070-2022
US

IV. Provider business mailing address

3400 DATA DR ATTN: CREDENTIALING/PAYER ENROLLMENT
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 650-596-9085
  • Fax: 650-596-9025
Mailing address:
  • Phone: 916-379-2861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG062720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: