Healthcare Provider Details

I. General information

NPI: 1417275462
Provider Name (Legal Business Name): JOSE LUIS SAN MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18945 FM 2252 STE 115
GARDEN RIDGE TX
78266-2797
US

IV. Provider business mailing address

275 S WORTHINGTON ST SPC 15
SPRING VALLEY CA
91977-6328
US

V. Phone/Fax

Practice location:
  • Phone: 210-651-0029
  • Fax:
Mailing address:
  • Phone: 619-475-8562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number96471
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: