Healthcare Provider Details

I. General information

NPI: 1144361403
Provider Name (Legal Business Name): DEER LAKES MEDICAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 ALLEGHENY RIVER BLVD
OAKMONT PA
15139-1848
US

IV. Provider business mailing address

5626 OBERLIN DR SUITE 110
SAN DIEGO CA
92121-1705
US

V. Phone/Fax

Practice location:
  • Phone: 412-767-5387
  • Fax:
Mailing address:
  • Phone: 858-625-2990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberMD053615L
License Number StatePA

VIII. Authorized Official

Name: MR. KENNY HEINE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 858-625-2990