Provider Demographics
NPI:1427062918
Name:PHILLIPS, VERNON GREG (MD)
Entity type:Individual
Prefix:MR
First Name:VERNON
Middle Name:GREG
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932
Mailing Address - Country:US
Mailing Address - Phone:619-429-7700
Mailing Address - Fax:619-429-7703
Practice Address - Street 1:707 PALM AVE
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932
Practice Address - Country:US
Practice Address - Phone:619-429-7700
Practice Address - Fax:619-429-7703
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG043409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G434090Medicaid
A49342Medicare UPIN
CA00G434090Medicaid