1578871786 NPI number — DELBERT L. SECRIST JR. M.D. A MEDICAL CORP.

Table of content: (NPI 1578871786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578871786 NPI number — DELBERT L. SECRIST JR. M.D. A MEDICAL CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELBERT L. SECRIST JR. M.D. A MEDICAL CORP.
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:
1578871786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 N. ACACIA AVE
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
SOLANA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92015-1130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-755-9324
Provider Business Mailing Address Fax Number:
760-751-9067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
141 N. ACACIA AVE.
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
SOLANA BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92015-1130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-755-9324
Provider Business Practice Location Address Fax Number:
760-751-9067
Provider Enumeration Date:
09/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SECRIST JR. M.D
Authorized Official First Name:
DELBERT
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
858-755-9324

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  G12084 , 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)





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