Healthcare Provider Details

I. General information

NPI: 1033375563
Provider Name (Legal Business Name): RICARDO A INDACOCHEA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E PALOMAR ST
CHULA VISTA CA
91913-1800
US

IV. Provider business mailing address

1400 E PALOMAR ST
CHULA VISTA CA
91913-1800
US

V. Phone/Fax

Practice location:
  • Phone: 858-499-2600
  • Fax:
Mailing address:
  • Phone: 858-499-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA110199
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA110199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: