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General NPI Number Information
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NPI Number | 1558503359
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Entity Type | Individual
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Provider Name | MITCHELL THOR GUDMUNDSSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/25/2009
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Last Update Date | 03/31/2015
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Provider Practice Location Address
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Address Line | 200 W. ARBOR DRIVE
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City | SAN DIEGO
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State | CA
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Zip | 92103-8756
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Country | US
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Telephone | 619-944-2347
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Fax |
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Provider Business Mailing Address
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Address Line | 1716 5TH ST
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City | MANHATTAN BEACH
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State | CA
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Zip | 90266-6313
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Country | US
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Telephone | 619-944-2347
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | 115317
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License Number State | CA
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