Healthcare Provider Details

I. General information

NPI: 1154588515
Provider Name (Legal Business Name): ABELLERA MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 MCKEE RD STE 1
SAN JOSE CA
95116-1617
US

IV. Provider business mailing address

2350 MCKEE RD STE 1
SAN JOSE CA
95116-1617
US

V. Phone/Fax

Practice location:
  • Phone: 408-272-0379
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA35884
License Number StateCA

VIII. Authorized Official

Name: DR. NILDA AGNES A ABELLERA
Title or Position: CEO/PRESIDENT
Credential: M.D.
Phone: 408-272-0379