Healthcare Provider Details

I. General information

NPI: 1174267835
Provider Name (Legal Business Name): MICHAEL RYAN BUCHHOLZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6010 HIDDEN VALLEY RD STE 115
CARLSBAD CA
92011-4219
US

IV. Provider business mailing address

4120 PILON PT
SAN DIEGO CA
92130-2205
US

V. Phone/Fax

Practice location:
  • Phone: 760-797-8494
  • Fax: 760-814-6094
Mailing address:
  • Phone: 858-926-6615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA205281
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRTL22-0065
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: