Healthcare Provider Details

I. General information

NPI: 1164572632
Provider Name (Legal Business Name): NATHALY MARIA COROMOTO SWEENEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 CAMPUS POINT DR # MC7774
LA JOLLA CA
92037-1300
US

IV. Provider business mailing address

9300 CAMPUS POINT DR # MC7774
LA JOLLA CA
92037-1300
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-3759
  • Fax: 619-543-3812
Mailing address:
  • Phone: 619-543-3759
  • Fax: 619-543-3812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP20264
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA110761
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberD67515
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA110761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: