Healthcare Provider Details

I. General information

NPI: 1639175433
Provider Name (Legal Business Name): BISSONETTE,FREY,GREENBERG,MALKUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6280 JACKSON DR STE 8
SAN DIEGO CA
92119-3436
US

IV. Provider business mailing address

6280 JACKSON DR STE 8
SAN DIEGO CA
92119-3436
US

V. Phone/Fax

Practice location:
  • Phone: 619-464-1607
  • Fax: 619-461-8662
Mailing address:
  • Phone: 619-464-1607
  • Fax: 619-461-8662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA77230
License Number StateCA

VIII. Authorized Official

Name: DR. DOUGLAS MATTHEW DAUB
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 619-464-1607