Healthcare Provider Details

I. General information

NPI: 1558409334
Provider Name (Legal Business Name): GEOFFREY P GROOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 KUHN DR STE 105
CHULA VISTA CA
91914-4517
US

IV. Provider business mailing address

860 KUHN DR STE 105
CHULA VISTA CA
91914-4517
US

V. Phone/Fax

Practice location:
  • Phone: 619-656-6311
  • Fax: 619-656-6134
Mailing address:
  • Phone: 619-656-6311
  • Fax: 619-656-6134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG51013
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: