Healthcare Provider Details

I. General information

NPI: 1457775850
Provider Name (Legal Business Name): CALVIN COLARUSSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 PROSPECT ST SUITE 415
LA JOLLA CA
92037-0068
US

IV. Provider business mailing address

1020 PROSPECT ST SUITE 415
LA JOLLA CA
92037-0068
US

V. Phone/Fax

Practice location:
  • Phone: 858-454-2473
  • Fax: 858-454-4192
Mailing address:
  • Phone: 858-454-2473
  • Fax: 858-454-4192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberC28845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: