Provider Demographics
NPI:1285906941
Name:CENTRAL VALLEY PEDIATRICS
Entity type:Organization
Organization Name:CENTRAL VALLEY PEDIATRICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:CANUTO
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-431-6600
Mailing Address - Street 1:7011 N HOWARD ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2955
Mailing Address - Country:US
Mailing Address - Phone:559-431-6600
Mailing Address - Fax:
Practice Address - Street 1:7011 N HOWARD ST
Practice Address - Street 2:SUITE 106
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2955
Practice Address - Country:US
Practice Address - Phone:559-431-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66119261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G661190Medicaid