1962456400 NPI number — RICHARD M AND DONALD R GREEN PTRS DBA SAN DIEGO PODIATRY GROUP

Table of content: (NPI 1962456400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962456400 NPI number — RICHARD M AND DONALD R GREEN PTRS DBA SAN DIEGO PODIATRY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD M AND DONALD R GREEN PTRS DBA SAN DIEGO PODIATRY GROUP
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:
SAN DIEGO PODIATRY GROUP
Provider Other Organization Name Type Code:
3
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:
1962456400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 CAMINO DEL RIO N
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92108-1621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-291-0777
Provider Business Mailing Address Fax Number:
619-291-3231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2650 CAMINO DEL RIO N
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108-1621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-291-0777
Provider Business Practice Location Address Fax Number:
619-291-3231
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CULLEN
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
619-291-0777

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ40809Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GRE000300 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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