MEDICARE: DR. REBECCA MARDACH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207SG0202X	Clinical Biochemical Genetics Physician	A45110	CA
2	208000000X	Pediatrics Physician	A45110	CA
3	207SG0201X	Clinical Genetics (M.D.) Physician	A45110	CA

General Provider Information

NPI Number	:	1457330607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REBECCA MARDACH MD

Provider Business Mailing Address
First Line	:	3020 CHILDRENS WAY # MC5003
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4223
Country	:	US
Telephone Number	:	858-309-6300
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 CHILDRENS WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123
Country	:	US
Telephone Number	:	619-543-7800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2006
Last Update Date	:	06/03/2019

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