=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073677811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA JOLLA SPINE INSTITUTE MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2006
-----------------------------------------------------
Last Update Date | 02/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6719 ALVARADO RD. SUITE 308
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-265-7912
-----------------------------------------------------
Fax | 619-265-7922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6719 ALVARADO ROAD SUITE 308
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-265-7912
-----------------------------------------------------
Fax | 619-265-7922
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RAMIN RAISZADEH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 619-265-7912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------