Healthcare Provider Details

I. General information

NPI: 1306842950
Provider Name (Legal Business Name): FERNANDO ANTONIO ZAMUDIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date: 03/29/2006
Reactivation Date: 03/29/2006

III. Provider practice location address

6655 ALVARADO RD
SAN DIEGO CA
92120-5208
US

IV. Provider business mailing address

PO BOX 22211
SAN DIEGO CA
92192-2211
US

V. Phone/Fax

Practice location:
  • Phone: 619-583-0511
  • Fax: 619-582-2012
Mailing address:
  • Phone: 619-583-0511
  • Fax: 619-582-2012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberC26245
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberC26245
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: