Healthcare Provider Details

I. General information

NPI: 1124165337
Provider Name (Legal Business Name): HEALTHCARE MEDICAL GROUP OF LA MESA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7339 EL CAJON BLVD SUITE I
LA MESA CA
91941-3435
US

IV. Provider business mailing address

7339 EL CAJON BLVD SUITE I
LA MESA CA
91941-3435
US

V. Phone/Fax

Practice location:
  • Phone: 619-698-0606
  • Fax: 619-698-0609
Mailing address:
  • Phone: 619-698-0606
  • Fax: 619-698-0609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA42653
License Number StateCA

VIII. Authorized Official

Name: DR. VENU PRABAKER
Title or Position: CEP
Credential: M..D.
Phone: 619-698-0606