Healthcare Provider Details

I. General information

NPI: 1073142659
Provider Name (Legal Business Name): NEYSAN PUCKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/04/2026
Certification Date: 04/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 HEALTH CENTER DR
SAN DIEGO CA
92123-2762
US

IV. Provider business mailing address

2929 HEALTH CENTER DR
SAN DIEGO CA
92123-2762
US

V. Phone/Fax

Practice location:
  • Phone: 858-939-5241
  • Fax: 503-413-6892
Mailing address:
  • Phone: 858-939-5241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD215330
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA203912
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: