Healthcare Provider Details

I. General information

NPI: 1417180290
Provider Name (Legal Business Name): XUEREN ZHAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

FILE 57326
LOS ANGELES CA
90074-0001
US

V. Phone/Fax

Practice location:
  • Phone: 800-926-8273
  • Fax: 888-539-8781
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberA105851
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberA105851
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License NumberA105851
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207UN0903X
TaxonomyIn Vivo & In Vitro Nuclear Medicine Physician
License NumberA105851
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberA105851
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: