Healthcare Provider Details

I. General information

NPI: 1548417868
Provider Name (Legal Business Name): GENE LAURENCE NATHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 EDGEMONT ST
SAN DIEGO CA
92102-1741
US

IV. Provider business mailing address

1344 EDGEMONT ST
SAN DIEGO CA
92102-1741
US

V. Phone/Fax

Practice location:
  • Phone: 619-392-4313
  • Fax: 619-281-2295
Mailing address:
  • Phone: 619-392-4313
  • Fax: 619-281-2295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG36717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: