Provider Demographics
NPI:1316175342
Name:MICHAEL S DUFFY SR DO INC
Entity type:Organization
Organization Name:MICHAEL S DUFFY SR DO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:DUFFY
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:619-647-5072
Mailing Address - Street 1:1501 5TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3224
Mailing Address - Country:US
Mailing Address - Phone:619-647-5072
Mailing Address - Fax:619-330-4782
Practice Address - Street 1:1501 5TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3224
Practice Address - Country:US
Practice Address - Phone:619-647-5072
Practice Address - Fax:619-309-6264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72004335V00000X
CA20A9616207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG63354Medicare UPIN
CX553AMedicare PIN