Healthcare Provider Details

I. General information

NPI: 1285828517
Provider Name (Legal Business Name): SCOTT DAVID INTRABARTOLO CRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11995 MOUNTAIN PASS RD
SAN DIEGO CA
92128-5261
US

IV. Provider business mailing address

PO BOX 1564
POWAY CA
92074-1564
US

V. Phone/Fax

Practice location:
  • Phone: 858-679-8770
  • Fax:
Mailing address:
  • Phone: 858-679-8770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberRHF48582
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: