Healthcare Provider Details

I. General information

NPI: 1538993001
Provider Name (Legal Business Name): VITALYZEMED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17137 RALPHS RANCH RD
SAN DIEGO CA
92127-7825
US

IV. Provider business mailing address

17137 RALPHS RANCH RD
SAN DIEGO CA
92127-7825
US

V. Phone/Fax

Practice location:
  • Phone: 570-205-8125
  • Fax:
Mailing address:
  • Phone: 570-205-8125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: TARIQ DASTAGIR
Title or Position: OWNER
Credential: MD
Phone: 570-205-8125