Healthcare Provider Details

I. General information

NPI: 1609268226
Provider Name (Legal Business Name): LA JOLLA CARDIOVASCULAR RESEARCH INSTITUTE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2015
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE SUITE 350
LA JOLLA CA
92037-1224
US

IV. Provider business mailing address

9850 GENESEE AVE SUITE 350
LA JOLLA CA
92037-1224
US

V. Phone/Fax

Practice location:
  • Phone: 858-886-7595
  • Fax:
Mailing address:
  • Phone: 858-886-7595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG062682
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberG062682
License Number StateCA

VIII. Authorized Official

Name: DR. ROBERT JOSEPH RUSSO
Title or Position: PHYSICIAN
Credential: MD PHD
Phone: 855-886-7595