Healthcare Provider Details

I. General information

NPI: 1700342748
Provider Name (Legal Business Name): SAN DIEGO UPTOWN PEDIATRIC MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 FIFTH AVE STE 101
SAN DIEGO CA
92103-5020
US

IV. Provider business mailing address

3500 FIFTH AVE STE 101
SAN DIEGO CA
92103-5020
US

V. Phone/Fax

Practice location:
  • Phone: 619-295-3911
  • Fax: 619-295-4356
Mailing address:
  • Phone: 619-295-3911
  • Fax: 619-295-4356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: HILARY KRAUSE
Title or Position: PHYSICIAN/CO-PRESIDENT
Credential: MD
Phone: 619-295-3911