Healthcare Provider Details

I. General information

NPI: 1194758219
Provider Name (Legal Business Name): ALLYSON A. KRESHAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR MAILCODE 8925
SAN DIEGO CA
92103-9001
US

IV. Provider business mailing address

200 W ARBOR DR MAILCODE 8925
SAN DIEGO CA
92103-9001
US

V. Phone/Fax

Practice location:
  • Phone: 267-872-3916
  • Fax: 858-715-6361
Mailing address:
  • Phone: 267-872-3916
  • Fax: 858-715-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD13560
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License NumberA102811
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA102811
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD424637
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: