1093861239 NPI number — ENRIQUE ESPINOSA-MELENDEZ MD INC

Table of content: KRISTINA N. TUTTLE CRNA (NPI 1962740738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093861239 NPI number — ENRIQUE ESPINOSA-MELENDEZ MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENRIQUE ESPINOSA-MELENDEZ MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093861239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3802 NATIONAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92113-3223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-264-2591
Provider Business Mailing Address Fax Number:
619-264-4116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3802 NATIONAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92113-3223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-264-2591
Provider Business Practice Location Address Fax Number:
619-264-4116
Provider Enumeration Date:
01/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AQUINO
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
BILLING REPRESENTATIVE
Authorized Official Telephone Number:
562-943-9559

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  C42745 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00C427451 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CLR333803 . This is a "CLIA LAB REGISTRATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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