Healthcare Provider Details

I. General information

NPI: 1689627317
Provider Name (Legal Business Name): LA JOLLA RADIOLOGY MEDICAL GROUP - DIAGNOSIS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 06/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 SORRENTO VALLEY RD SUITE 320
SAN DIEGO CA
92121-1635
US

IV. Provider business mailing address

P.O. BOX 2570
NEWBURY PARK CA
91319-2570
US

V. Phone/Fax

Practice location:
  • Phone: 858-454-4235
  • Fax: 858-454-4644
Mailing address:
  • Phone: 800-386-8024
  • Fax: 805-375-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER H.B. MCCREIGHT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 858-454-4235