Provider Demographics
NPI:1811985542
Name:WINE, DAVID TODD (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:TODD
Last Name:WINE
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 1:2067 W VISTA WAY
Mailing Address - Street 2:#200
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6031
Mailing Address - Country:US
Mailing Address - Phone:760-726-2180
Mailing Address - Fax:760-630-5716
Practice Address - Street 1:2067 W VISTA WAY
Practice Address - Street 2:#200
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6031
Practice Address - Country:US
Practice Address - Phone:760-726-2180
Practice Address - Fax:760-726-9928
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45531207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50078Medicare UPIN