1437170354 NPI number — ANGEL M. SAN JOSE, M.D., P.C.

Table of content: (NPI 1437170354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437170354 NPI number — ANGEL M. SAN JOSE, M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGEL M. SAN JOSE, M.D., P.C.
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:
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:
1437170354
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:
RR 5 BOX 20
Provider Second Line Business Mailing Address:
SUITE 207
Provider Business Mailing Address City Name:
GRUNDY
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24614-9611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-935-1168
Provider Business Mailing Address Fax Number:
276-935-1343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RR 5 BOX 20
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
GRUNDY
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24614-9611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-935-1168
Provider Business Practice Location Address Fax Number:
276-935-1343
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAN JOSE
Authorized Official First Name:
ANGEL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
276-935-1168

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  0101238113 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 64113434 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 187487 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 3810003447 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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