MEDICARE: CHOICE MEDICAL CLINIC, INC

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	207VG0400X	Gynecology Physician	GR0006547	CA

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

General Provider Information

NPI Number	:	1740377811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHOICE MEDICAL CLINIC, INC

Provider Business Mailing Address
First Line	:	1834 STONE AVE
Second Line	:	SUITE 2B
City	:	SAN JOSE
State	:	CA
Zip	:	95125-1306
Country	:	US
Telephone Number	:	408-995-0102
Fax Number	:	408-995-0190

Provider Business Practice Location Address
First Line	:	2365 MONTPELIER DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95116-1614
Country	:	US
Telephone Number	:	408-272-9244
Fax Number	:	408-254-4596

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	LIZA TAPIA VAUGHAN
Credential	:
Telephone Number	:	408-995-0102

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	08/22/2020

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