=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801880786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE MELITON MEDRANO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2005
-----------------------------------------------------
Last Update Date | 07/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 191 S BUENA VISTA ST SUITE: 300
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-4554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-846-8981
-----------------------------------------------------
Fax | 818-846-8985
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 191 S BUENA VISTA ST SUITE: 300
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-4554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-846-8981
-----------------------------------------------------
Fax | 818-846-8985
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | A75641
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------