Healthcare Provider Details

I. General information

NPI: 1063664472
Provider Name (Legal Business Name): RACHEL KURNIADI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 CAMINO DE LA SIESTA SUITE 208
SAN DIEGO CA
92108-3116
US

IV. Provider business mailing address

5030 CAMINO DE LA SIESTA SUITE 208
SAN DIEGO CA
92108-3116
US

V. Phone/Fax

Practice location:
  • Phone: 619-260-6300
  • Fax: 858-373-2447
Mailing address:
  • Phone: 619-260-6300
  • Fax: 858-373-2447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA41752
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA41752
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: