Healthcare Provider Details

I. General information

NPI: 1881701332
Provider Name (Legal Business Name): CHILDRENS HEALTHCARE MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 WASHINGTON ST SUITE 300
SAN DIEGO CA
92103-2213
US

IV. Provider business mailing address

550 WASHINGTON ST SUITE 300
SAN DIEGO CA
92103-2213
US

V. Phone/Fax

Practice location:
  • Phone: 619-237-5437
  • Fax: 619-243-0722
Mailing address:
  • Phone: 619-237-5437
  • Fax: 619-243-0722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG393080
License Number StateCA

VIII. Authorized Official

Name: DR. STEPHEN H CARSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 619-297-5437