Provider Demographics
NPI:1154588515
Name:ABELLERA MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:ABELLERA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NILDA AGNES
Authorized Official - Middle Name:A
Authorized Official - Last Name:ABELLERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-272-0379
Mailing Address - Street 1:2350 MCKEE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2350 MCKEE RD STE 1
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1617
Practice Address - Country:US
Practice Address - Phone:408-272-0379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35884261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0705196OtherCLIA
CAA035884Medicare PIN
CAA27932Medicare UPIN