Provider Demographics
NPI:1316905334
Name:MEDRANO, SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MEDRANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 N CALIFORNIA BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-3742
Mailing Address - Country:US
Mailing Address - Phone:925-225-5837
Mailing Address - Fax:
Practice Address - Street 1:199 E WEBSTER ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2954
Practice Address - Country:US
Practice Address - Phone:530-458-3283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68235207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G682350Medicaid
CA00G682350Medicare PIN
CA00G682355Medicare PIN
F41456Medicare UPIN