Provider Demographics
NPI:1932257193
Name:SAN DIEGO PRIMARY CARE MEDICAL GROUP
Entity type:Organization
Organization Name:SAN DIEGO PRIMARY CARE MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-292-8885
Mailing Address - Street 1:3737 MORAGA AVE
Mailing Address - Street 2:STE B408
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5364
Mailing Address - Country:US
Mailing Address - Phone:858-292-8885
Mailing Address - Fax:858-292-0688
Practice Address - Street 1:3737 MORAGA AVE
Practice Address - Street 2:STE B408
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5364
Practice Address - Country:US
Practice Address - Phone:858-292-8885
Practice Address - Fax:858-292-0688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-06
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
CAG31968207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G319680Medicaid
CA00G319680Medicaid
CAA44934Medicare UPIN