Provider Demographics
NPI:1063405637
Name:SAN DIEGO SPINE & SPORT, INC
Entity type:Organization
Organization Name:SAN DIEGO SPINE & SPORT, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-751-0900
Mailing Address - Street 1:450 4TH AVE
Mailing Address - Street 2:#215
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4426
Mailing Address - Country:US
Mailing Address - Phone:619-585-3745
Mailing Address - Fax:619-585-3746
Practice Address - Street 1:450 4TH AVE
Practice Address - Street 2:#215
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4426
Practice Address - Country:US
Practice Address - Phone:619-585-3745
Practice Address - Fax:619-585-3746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomicsGroup - Multi-Specialty
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Multi-Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWC20677IMedicare ID - Type UnspecifiedV MOONEY
CAWOT32AMedicare ID - Type UnspecifiedW HILL
CAWOT6210BMedicare ID - Type UnspecifiedJ HONATH
CAWOT243BMedicare ID - Type UnspecifiedA LUDWIG
CAB24978Medicare UPIN
CAWPT28041AMedicare ID - Type UnspecifiedD SAUNDERS
CAWPT22895FMedicare ID - Type UnspecifiedP CLAY
CAW15369Medicare ID - Type UnspecifiedGROUP ID