Healthcare Provider Details

I. General information

NPI: 1457494361
Provider Name (Legal Business Name): SAN DIEGO FERTILITY CENTER MEDICAL GROUP,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11425 EL CAMINO REAL
SAN DIEGO CA
92130-2045
US

IV. Provider business mailing address

11425 EL CAMINO REAL
SAN DIEGO CA
92130-2045
US

V. Phone/Fax

Practice location:
  • Phone: 858-794-6363
  • Fax: 858-794-6360
Mailing address:
  • Phone: 858-794-6363
  • Fax: 858-794-6360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA VANDOLAH
Title or Position: CEO
Credential: RN,MBA
Phone: 858-720-3177