Healthcare Provider Details

I. General information

NPI: 1821055427
Provider Name (Legal Business Name): NUBIA MEDINA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HIGHLAND AVE VHC SAN MARTIN FAMILY PRACTICE CLINIC
SAN MARTIN CA
95046-9504
US

IV. Provider business mailing address

751 S BASCOM AVE
SAN JOSE CA
95128-2604
US

V. Phone/Fax

Practice location:
  • Phone: 408-686-2233
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA45279
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: