Healthcare Provider Details

I. General information

NPI: 1679005128
Provider Name (Legal Business Name): PHILLIP MILGRAM MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4080 CENTRE ST SUITE 105
SAN DIEGO CA
92103-2655
US

IV. Provider business mailing address

4080 CENTRE ST SUITE 105
SAN DIEGO CA
92103-2655
US

V. Phone/Fax

Practice location:
  • Phone: 844-623-7587
  • Fax:
Mailing address:
  • Phone: 844-623-7587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberA35411
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberA35411
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA35411
License Number StateCA

VIII. Authorized Official

Name: PHILIP MARK MILGRAM
Title or Position: OFFICER
Credential: MD
Phone: 844-623-7587