=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407960362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STANLEY DEAN SKAGGS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2006
-----------------------------------------------------
Last Update Date | 03/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3525 DEL MAR HEIGHTS RD 282
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-554-0120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3525 DEL MAR HEIGHTS RD 282
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-554-0120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | G39245
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------