Healthcare Provider Details

I. General information

NPI: 1376834077
Provider Name (Legal Business Name): GATEWAY COMPREHENSIVE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 GATEWAY CENTER WAY STE 105
SAN DIEGO CA
92102-4544
US

IV. Provider business mailing address

PO BOX 181770
CORONADO CA
92178-1770
US

V. Phone/Fax

Practice location:
  • Phone: 619-264-1934
  • Fax:
Mailing address:
  • Phone: 619-264-1934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA54452
License Number StateCA

VIII. Authorized Official

Name: DR. TAREK I HASSANEIN
Title or Position: MD
Credential: MD
Phone: 619-264-1934