Healthcare Provider Details

I. General information

NPI: 1285737569
Provider Name (Legal Business Name): PHILLIP MARK MILGRAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 05/28/2023
Certification Date: 05/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3262 HOLIDAY CT STE 210
LA JOLLA CA
92037-1811
US

IV. Provider business mailing address

444 N EL CAMINO REAL SPC 123
ENCINITAS CA
92024-1317
US

V. Phone/Fax

Practice location:
  • Phone: 760-944-9200
  • Fax: 760-692-4411
Mailing address:
  • Phone: 760-944-9200
  • Fax: 760-692-4411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberA35411
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA35411
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberA35411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: