Basic Information
| Provider Information | |||||||||
| NPI: | 1891753315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CEJA | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2061 ROSS AVE STE B | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922433687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603573768 | ||||||||
| FaxNumber: | 7603557731 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 WEST COLE BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | CALEXICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922319722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603573768 | ||||||||
| FaxNumber: | 8773551742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G79700 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G79700 | 05 | CA | MEDICAID | WG79700A | 01 | CA | MEDICARE PTAN | OTHER | ZZZ47481Z | 01 | CA | BLUE SHIELD ZZZ # | OTHER | W13536B | 01 | CA | MEDICARE GROUP # | OTHER | GR0066312 | 01 | CA | MEDI-CAL GROUP # | OTHER |