Healthcare Provider Details

I. General information

NPI: 1255613402
Provider Name (Legal Business Name): RONALD MELVIN BEDFORD JR. NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 N HARBOR DR STE 200
SAN DIEGO CA
92106-2386
US

IV. Provider business mailing address

5000 N HARBOR DR STE 200
SAN DIEGO CA
92106-2386
US

V. Phone/Fax

Practice location:
  • Phone: 760-847-7948
  • Fax:
Mailing address:
  • Phone: 760-472-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: