MEDICARE: MERIDIAN MEDICAL GROUP PROFESSIONAL CORP

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	208D00000X	General Practice Physician	A303360	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	880357380	OTHER	CA	TAX ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	00A303360	OTHER	CA	MEDICAL LICENSE NUMBER
5	1134228752	OTHER	CA	NPI NUMBER
6	ZZZ41448Z	OTHER	CA	BLUE SHIELD NUMBER
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457439572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERIDIAN MEDICAL GROUP PROFESSIONAL CORP

Provider Business Mailing Address
First Line	:	1047 E CAPITOL EXPY
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95121-2415
Country	:	US
Telephone Number	:	408-754-8988
Fax Number	:	408-754-8289

Provider Business Practice Location Address
First Line	:	1047 E CAPITOL EXPY
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95121-2415
Country	:	US
Telephone Number	:	408-754-8988
Fax Number	:	408-754-8289

Authorized Official
Title or Position	:	CEO
Name	:	DR. ALBERT A GOMEZ
Credential	:	MD
Telephone Number	:	408-754-8988

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	03/29/2021

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Directions to “MERIDIAN MEDICAL GROUP PROFESSIONAL CORP ” Practice Location

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