Healthcare Provider Details

I. General information

NPI: 1235206293
Provider Name (Legal Business Name): CASSIDY MEDICAL GROUP -PEDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2067 W VISTA WAY STE 280
VISTA CA
92083-6034
US

IV. Provider business mailing address

2067 W VISTA WAY STE 280
VISTA CA
92083-6034
US

V. Phone/Fax

Practice location:
  • Phone: 760-941-3630
  • Fax: 760-941-1214
Mailing address:
  • Phone: 760-941-3630
  • Fax: 760-941-1214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JUDITH M KRUEGER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 760-630-5487