Provider Demographics
NPI:1063768091
Name:UNIVERSITY OF CALIFORNIA, SAN DIEGO
Entity type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA, SAN DIEGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:PANNIZON
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:619-542-4156
Mailing Address - Street 1:11223 PASEO MONTANOSO APT 282
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5953
Mailing Address - Country:US
Mailing Address - Phone:760-518-3119
Mailing Address - Fax:
Practice Address - Street 1:3851 ROSECRANS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3115
Practice Address - Country:US
Practice Address - Phone:619-542-4156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare