Healthcare Provider Details

I. General information

NPI: 1437184421
Provider Name (Legal Business Name): PAUL T ISHIMINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 CAMPUS POINT DRIVE
LA JOLLA CA
92037
US

IV. Provider business mailing address

FILE NO. 54826
LOS ANGELES CA
90074-4826
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-7000
  • Fax:
Mailing address:
  • Phone: 888-486-4380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA79142
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberA79142
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: