Healthcare Provider Details

I. General information

NPI: 1174582001
Provider Name (Legal Business Name): WINSTON CAESAR MINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 11/18/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10990 SAN DIEGO MISSION RD
SAN DIEGO CA
92108-2417
US

IV. Provider business mailing address

10990 SAN DIEGO MISSION RD
SAN DIEGO CA
92108-2417
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-1245
  • Fax: 619-641-4099
Mailing address:
  • Phone: 619-528-1245
  • Fax: 619-641-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number114879
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberC130288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: