Healthcare Provider Details

I. General information

NPI: 1679271829
Provider Name (Legal Business Name): MARY MARGARET VANSANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

3489 BOB WILSON DR
SAN DIEGO CA
92134-5000
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6400
  • Fax:
Mailing address:
  • Phone: 618-881-9169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101283077
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: