Healthcare Provider Details

I. General information

NPI: 1871075457
Provider Name (Legal Business Name): REBECCA SHELLEY CAMACHO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date: 05/02/2024
Reactivation Date: 06/13/2024

III. Provider practice location address

2535 KETTNER BLVD STE 1A4
SAN DIEGO CA
92101-1252
US

IV. Provider business mailing address

2535 KETTNER BLVD STE 1A4
SAN DIEGO CA
92101-1252
US

V. Phone/Fax

Practice location:
  • Phone: 619-615-0701
  • Fax:
Mailing address:
  • Phone: 619-615-0701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125084180
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125084180
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: