Provider Demographics
NPI:1306433032
Name:SAN DIEGO PEDIATRIC NEUROLOGY, INC.
Entity type:Organization
Organization Name:SAN DIEGO PEDIATRIC NEUROLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHAELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-598-5472
Mailing Address - Street 1:8555 AERO DR STE 340
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1740
Mailing Address - Country:US
Mailing Address - Phone:858-384-7828
Mailing Address - Fax:858-598-6344
Practice Address - Street 1:3003 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2700
Practice Address - Country:US
Practice Address - Phone:858-939-4185
Practice Address - Fax:858-939-4972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-29
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty