Provider Demographics
NPI:1407957673
Name:SAN DIEGO GENERAL AND VASCULAR SURGEONS MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:SAN DIEGO GENERAL AND VASCULAR SURGEONS MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELTRAN LUMN
Authorized Official - Suffix:
Authorized Official - Credentials:BOM
Authorized Official - Phone:858-565-0104
Mailing Address - Street 1:7910 FROST ST STE 250
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2752
Mailing Address - Country:US
Mailing Address - Phone:858-565-0104
Mailing Address - Fax:858-565-0194
Practice Address - Street 1:7910 FROST ST STE 250
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2752
Practice Address - Country:US
Practice Address - Phone:858-565-0104
Practice Address - Fax:858-565-0194
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN DIEGO GENERAL AND VASCULAR SURGEONS MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-26
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid