Healthcare Provider Details

I. General information

NPI: 1164901237
Provider Name (Legal Business Name): GEN 5 FERTILITY CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 CARMEL MOUNTAIN RD STE 200
SAN DIEGO CA
92121-1069
US

IV. Provider business mailing address

3420 CARMEL MOUNTAIN RD STE 200
SAN DIEGO CA
92121-1069
US

V. Phone/Fax

Practice location:
  • Phone: 858-267-4365
  • Fax:
Mailing address:
  • Phone: 858-267-4365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberG68058
License Number StateCA

VIII. Authorized Official

Name: SAMUEL WOOD
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 858-267-4365