Healthcare Provider Details

I. General information

NPI: 1821167628
Provider Name (Legal Business Name): MINIMALLY INVASIVE SURGICAL SOLUTIONS MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N BASCOM AVE STE 104
SAN JOSE CA
95128-1811
US

IV. Provider business mailing address

105 N BASCOM AVE STE 104
SAN JOSE CA
95128-1811
US

V. Phone/Fax

Practice location:
  • Phone: 408-918-0405
  • Fax: 408-918-0409
Mailing address:
  • Phone: 408-918-0405
  • Fax: 408-918-0409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARIA ANDRADE
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 408-918-0405