1063596021 NPI number — ANA MARIE PILAR DESOTO PHD

Table of content: ANA MARIE PILAR DESOTO PHD (NPI 1063596021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063596021 NPI number — ANA MARIE PILAR DESOTO PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESOTO
Provider First Name:
ANA MARIE
Provider Middle Name:
PILAR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

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:
1063596021
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 FESLER ST
Provider Second Line Business Mailing Address:
STE 205
Provider Business Mailing Address City Name:
EL CAJON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92020-1968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-579-9346
Provider Business Mailing Address Fax Number:
619-579-9304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 FESLER ST
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92020-1968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-579-9346
Provider Business Practice Location Address Fax Number:
619-579-9304
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY11402 , 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: PSY114020 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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