Provider Demographics
NPI:1386490423
Name:MEDINA ONTIVEROS, JORGE ARMANDO
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ARMANDO
Last Name:MEDINA ONTIVEROS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 MAX AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-5250
Mailing Address - Country:US
Mailing Address - Phone:619-621-4836
Mailing Address - Fax:
Practice Address - Street 1:3002 ARMSTRONG ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5702
Practice Address - Country:US
Practice Address - Phone:858-633-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No172V00000XOther Service ProvidersCommunity Health Worker