Healthcare Provider Details

I. General information

NPI: 1649451493
Provider Name (Legal Business Name): CLINICA MEDICA PEDIATRICA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 NATIONAL AVE
SAN DIEGO CA
92113-3223
US

IV. Provider business mailing address

3802 NATIONAL AVE
SAN DIEGO CA
92113-3223
US

V. Phone/Fax

Practice location:
  • Phone: 619-264-2591
  • Fax:
Mailing address:
  • Phone: 619-264-2591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA42572
License Number StateCA

VIII. Authorized Official

Name: MARIO E EYZAGUIRRE
Title or Position: DIRECTOR
Credential: MD
Phone: 619-264-2591