Provider Demographics
NPI:1962597807
Name:ADVANCED CALIFORNIA MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:ADVANCED CALIFORNIA MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEENA
Authorized Official - Middle Name:S
Authorized Official - Last Name:TAJRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACOG
Authorized Official - Phone:858-578-9600
Mailing Address - Street 1:1934 VIA CASA ALTA
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5730
Mailing Address - Country:US
Mailing Address - Phone:858-578-9600
Mailing Address - Fax:858-578-9065
Practice Address - Street 1:10737 CAMINO RUIZ
Practice Address - Street 2:SUITE 114
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2359
Practice Address - Country:US
Practice Address - Phone:858-578-9600
Practice Address - Fax:858-578-9065
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED CALIFORNIA MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-04
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55154207R00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ65932ZOtherBLUE SHIELD CA
CAZZZ65933ZOtherBLUE SHIELD CA
774581OtherBLUE SHIELD CA
CA00A551540Medicaid
CAZZZ65931ZOtherBLUE SHIELD CA
CA00A551540Medicaid
774581OtherBLUE SHIELD CA