Healthcare Provider Details

I. General information

NPI: 1912122680
Provider Name (Legal Business Name): GARY VANDENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9834 GENESEE AVE SUITE 326
LA JOLLA CA
92037-1223
US

IV. Provider business mailing address

9834 GENESEE AVE SUITE 326
LA JOLLA CA
92037-1223
US

V. Phone/Fax

Practice location:
  • Phone: 858-453-3813
  • Fax: 858-453-1727
Mailing address:
  • Phone: 858-453-3813
  • Fax: 858-453-1727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberC33053
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: