Provider Demographics
NPI:1730392788
Name:PACIFIC NEUROLOGY AMC
Entity type:Organization
Organization Name:PACIFIC NEUROLOGY AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LASKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-443-0282
Mailing Address - Street 1:3737 MORAGA AVE STE A5
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5459
Mailing Address - Country:US
Mailing Address - Phone:619-443-0282
Mailing Address - Fax:619-443-5337
Practice Address - Street 1:3737 MORAGA AVE STE A5
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5459
Practice Address - Country:US
Practice Address - Phone:619-443-0282
Practice Address - Fax:619-443-5337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG5479102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18192Medicare ID - Type Unspecified