1932200367 NPI number — SAN DIEGO VITREORETINAL ASSOCIATES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932200367 NPI number — SAN DIEGO VITREORETINAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN DIEGO VITREORETINAL ASSOCIATES
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:
1932200367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9834 GENESEE AVENUE
Provider Second Line Business Mailing Address:
SUITE 315
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-1221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-457-4090
Provider Business Mailing Address Fax Number:
858-457-1543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9834 GENESEE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 315
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-1221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-457-4090
Provider Business Practice Location Address Fax Number:
858-457-1543
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DALY
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
TERENCE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-457-4090

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  G26296 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR006892 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0068981 . This is a "MEDI CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0068982 . This is a "MEDI CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0068983 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ61560Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0068981 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180032742 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: ZZZ55528Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0068980 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0068983 . This is a "MEDI CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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