Healthcare Provider Details

I. General information

NPI: 1457330607
Provider Name (Legal Business Name): REBECCA MARDACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA MARDACH-VERDON M.D.

II. Dates (important events)

Enumeration Date: 01/14/2006
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 CHILDRENS WAY
SAN DIEGO CA
92123
US

IV. Provider business mailing address

3020 CHILDRENS WAY # MC5003
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-7800
  • Fax:
Mailing address:
  • Phone: 858-309-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0202X
TaxonomyClinical Biochemical Genetics Physician
License NumberA45110
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA45110
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberA45110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: