Healthcare Provider Details

I. General information

NPI: 1255717377
Provider Name (Legal Business Name): UCSD DEPARTMENT OF PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 FORST ST SUITE 100
SAN DIEGO CA
92123
US

IV. Provider business mailing address

5531 LADYBIRD LN
LA JOLLA CA
92037-7721
US

V. Phone/Fax

Practice location:
  • Phone: 858-246-1738
  • Fax: 858-246-1793
Mailing address:
  • Phone: 858-761-1308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License NumberSFP000030
License Number StateCA

VIII. Authorized Official

Name: PROF. KENNETH LYONS JONES
Title or Position: DIVISION CHIEF
Credential: M.D.
Phone: 858-246-1738