Healthcare Provider Details

I. General information

NPI: 1073574380
Provider Name (Legal Business Name): KURT ANDIVAL HENRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 CAMINO DEL RIO N STE 200
SAN DIEGO CA
92108-1745
US

IV. Provider business mailing address

3530 CAMINO DEL RIO N STE 200
SAN DIEGO CA
92108-1745
US

V. Phone/Fax

Practice location:
  • Phone: 619-674-0111
  • Fax: 619-228-9877
Mailing address:
  • Phone: 619-674-0111
  • Fax: 619-228-9877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberC138416
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101237730
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME69825
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number0101237730
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC138416
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: