Healthcare Provider Details

I. General information

NPI: 1629187323
Provider Name (Legal Business Name): EVAN YALE SNYDER M.D., PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 DICKINSON ST
SAN DIEGO CA
92103-6902
US

IV. Provider business mailing address

722 GLENVIEW LN
LA JOLLA CA
92037-5424
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-3794
  • Fax:
Mailing address:
  • Phone: 858-729-1984
  • Fax: 858-795-5273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG86951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: