Healthcare Provider Details

I. General information

NPI: 1841596301
Provider Name (Legal Business Name): VA SAN DIEGO HEALTHCARE SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4260 PORTE DE PALMAS UNIT 60
SAN DIEGO CA
92122-5159
US

IV. Provider business mailing address

4260 PORTE DE PALMAS UNIT 60
SAN DIEGO CA
92122-5159
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-8585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberTRAINEE
License Number State

VIII. Authorized Official

Name: DR. SHAFAGH MONAZZAM
Title or Position: RESIDENT
Credential: M.D.
Phone: 714-595-2250