Healthcare Provider Details

I. General information

NPI: 1689860108
Provider Name (Legal Business Name): CARMEL VALLEY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 EL CAMINO REAL SUITE 315
SAN DIEGO CA
92130-3082
US

IV. Provider business mailing address

12395 EL CAMINO REAL SUITE 315
SAN DIEGO CA
92130-3082
US

V. Phone/Fax

Practice location:
  • Phone: 858-794-5437
  • Fax: 858-794-5439
Mailing address:
  • Phone: 858-794-5437
  • Fax: 858-794-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC50161
License Number StateCA

VIII. Authorized Official

Name: DR. CHRYSTAL DE FREITAS
Title or Position: OWNER
Credential: M.D.
Phone: 858-794-5437