1811016934 NPI number — VENN-WATSON MEDICAL CORPORATION

Table of content: (NPI 1811016934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811016934 NPI number — VENN-WATSON MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VENN-WATSON MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811016934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18737 LUNADA PT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92128-1116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-487-4575
Provider Business Mailing Address Fax Number:
858-487-4148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-5716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-293-3994
Provider Business Practice Location Address Fax Number:
619-295-7389
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VENN-WATSON
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
ARTHUR
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-487-4575

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  G22012 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2048917 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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