Healthcare Provider Details

I. General information

NPI: 1619154689
Provider Name (Legal Business Name): LEILA BOLANDGRAY, M.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

PO BOX 2775
LA MESA CA
91943-2775
US

V. Phone/Fax

Practice location:
  • Phone: 619-937-6349
  • Fax: 866-313-8916
Mailing address:
  • Phone: 619-937-6349
  • Fax: 866-313-8916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA72176
License Number StateCA

VIII. Authorized Official

Name: DR. LEILA SOFIA BOLANDGRAY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 619-937-6349