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General NPI Number Information
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NPI Number | 1275815946
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Entity Type | Organization
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Legal Business Name | MEDMEK MEDICAL CLINIC, INC.
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Dates
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Enumeration Date | 09/19/2011
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Last Update Date | 09/19/2011
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Provider Practice Location Address
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Address Line | 433 TUOLUMNE ST SUITE
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City | VALLEJO
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State | CA
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Zip | 94590-5764
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Country | US
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Telephone | 510-230-3817
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5133
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City | HERCULES
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State | CA
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Zip | 94547-5133
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Country | US
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Telephone | 510-230-3817
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Fax |
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Authorized Official
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Title or Position | SECRETARY
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Name | AUGUSTINE MEKKAM
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Credential | MD
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Telephone | 510-230-3817
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | G77245
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License Number State | CA
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