Healthcare Provider Details

I. General information

NPI: 1043215502
Provider Name (Legal Business Name): ALFREDO B. TIU D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR OWEN CLINIC
SAN DIEGO CA
92103-9001
US

IV. Provider business mailing address

200 W ARBOR DR OWEN CLINIC
SAN DIEGO CA
92103-9001
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-2415
  • Fax: 619-543-2415
Mailing address:
  • Phone: 619-543-2415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number20A7678
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: