Healthcare Provider Details

I. General information

NPI: 1336393990
Provider Name (Legal Business Name): AMELIA STAR EASTMAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 CAMPUS POINT DR STE. 1B
LA JOLLA CA
92037-1300
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-8200
  • Fax: 858-657-8235
Mailing address:
  • Phone: 858-249-6749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number20A11643
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number20A 11643
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: