Healthcare Provider Details

I. General information

NPI: 1316175342
Provider Name (Legal Business Name): MICHAEL S DUFFY SR DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 5TH AVE STE 200
SAN DIEGO CA
92101-3224
US

IV. Provider business mailing address

1501 5TH AVE STE 200
SAN DIEGO CA
92101-3224
US

V. Phone/Fax

Practice location:
  • Phone: 619-647-5072
  • Fax: 619-309-6264
Mailing address:
  • Phone: 619-647-5072
  • Fax: 619-330-4782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A9616
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number72004
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL SEAN DUFFY SR.
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 619-647-5072