Healthcare Provider Details

I. General information

NPI: 1154312775
Provider Name (Legal Business Name): UCSD MED-CYTOGENETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GILMAN DRIVE MAIL CODE 0639
LA JOLLA CA
92093-0639
US

IV. Provider business mailing address

9500 GILMAN DR MAIL CODE 0639
LA JOLLA CA
92093-0639
US

V. Phone/Fax

Practice location:
  • Phone: 858-534-4308
  • Fax: 858-534-0269
Mailing address:
  • Phone: 858-534-4308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLIA05D0643070
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number05D0643070
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLF4717
License Number StateCA

VIII. Authorized Official

Name: DR. MARIE DELL'AQUILA PHD
Title or Position: DIRECTOR
Credential: PHD
Phone: 858-534-4308