Healthcare Provider Details

I. General information

NPI: 1871752451
Provider Name (Legal Business Name): MATEJKA CERNELC-KOHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8110 BIRMINGHAM WAY
SAN DIEGO CA
92123-2758
US

IV. Provider business mailing address

3020 CHILDRENS WAY MC5003
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5846
  • Fax: 858-569-9052
Mailing address:
  • Phone: 858-309-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberA116947
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: