Healthcare Provider Details

I. General information

NPI: 1326603028
Provider Name (Legal Business Name): JACQUELINE BROGAN MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 PROSPECT PL STE 260
CORONADO CA
92118-1987
US

IV. Provider business mailing address

246 5TH ST
ENCINITAS CA
92024-3256
US

V. Phone/Fax

Practice location:
  • Phone: 619-437-1146
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE BROGAN
Title or Position: PARTNER
Credential: MD
Phone: 805-331-1763