Provider Demographics
NPI:1932353166
Name:SUNNYSIDE MEDICAL CLINIS
Entity type:Organization
Organization Name:SUNNYSIDE MEDICAL CLINIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LOPEZ
Authorized Official - Last Name:IBARRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-255-0496
Mailing Address - Street 1:5561 E KINGS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-4528
Mailing Address - Country:US
Mailing Address - Phone:559-255-0496
Mailing Address - Fax:559-253-0510
Practice Address - Street 1:5561 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-4528
Practice Address - Country:US
Practice Address - Phone:559-255-0496
Practice Address - Fax:559-253-0510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73482261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G734820Medicare PIN
CAE76803Medicare UPIN