MEDICARE: ANGEL M. SAN JOSE, M.D., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	0101238113	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	187487	OTHER	VA	ANTHEM BLUE CROSS BLUE SH
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437170354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGEL M. SAN JOSE, M.D., P.C.

Provider Business Mailing Address
First Line	:	RR 5 BOX 20
Second Line	:	SUITE 207
City	:	GRUNDY
State	:	VA
Zip	:	24614-9611
Country	:	US
Telephone Number	:	276-935-1168
Fax Number	:	276-935-1343

Provider Business Practice Location Address
First Line	:	RR 5 BOX 20
Second Line	:	SUITE 207
City	:	GRUNDY
State	:	VA
Zip	:	24614-9611
Country	:	US
Telephone Number	:	276-935-1168
Fax Number	:	276-935-1343

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANGEL M SAN JOSE
Credential	:	M.D.
Telephone Number	:	276-935-1168

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	08/22/2020

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