Healthcare Provider Details

I. General information

NPI: 1740603471
Provider Name (Legal Business Name): GINES D MIRALLES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 VIA FRESA
LA JOLLA CA
92037-6944
US

IV. Provider business mailing address

2235 VIA FRESA
LA JOLLA CA
92037-6944
US

V. Phone/Fax

Practice location:
  • Phone: 858-784-3070
  • Fax:
Mailing address:
  • Phone: 858-784-3070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberC54325
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: