Healthcare Provider Details

I. General information

NPI: 1548379225
Provider Name (Legal Business Name): RAYMOND A FIDALEO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7850 VISTA HILL AVENUE
SAN DIEGO CA
92103
US

IV. Provider business mailing address

PO BOX 34190
SAN DIEGO CA
92163
US

V. Phone/Fax

Practice location:
  • Phone: 858-694-8399
  • Fax: 858-278-5920
Mailing address:
  • Phone: 858-694-8399
  • Fax: 858-278-5920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG11749
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: