Healthcare Provider Details

I. General information

NPI: 1083703805
Provider Name (Legal Business Name): ERNEST V. BELEZZUOLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-7511
  • Fax:
Mailing address:
  • Phone: 858-552-7511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberG74168
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: