Healthcare Provider Details

I. General information

NPI: 1558503359
Provider Name (Legal Business Name): MITCHELL THOR GUDMUNDSSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W. ARBOR DRIVE
SAN DIEGO CA
92103-8756
US

IV. Provider business mailing address

1716 5TH ST
MANHATTAN BEACH CA
90266-6313
US

V. Phone/Fax

Practice location:
  • Phone: 619-944-2347
  • Fax:
Mailing address:
  • Phone: 619-944-2347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number115317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: