Healthcare Provider Details

I. General information

NPI: 1669661815
Provider Name (Legal Business Name): UNIVERSITY OF CALIFORNIA, SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 CAMPUS POINT DR STE 2D
LA JOLLA CA
92037-1300
US

IV. Provider business mailing address

9310 CAMPUS POINT DR STE B
LA JOLLA CA
92037-1300
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-7206
  • Fax: 858-657-7201
Mailing address:
  • Phone: 858-657-7206
  • Fax: 858-657-7201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QG0250X
TaxonomyGenetics Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: JASON CHIBUK
Title or Position: LEAD GENETIC COUNSELOR
Credential: M.S., CGC
Phone: 858-657-7212