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General NPI Number Information
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NPI Number | 1679620868
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Entity Type | Organization
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Legal Business Name | BALBOA PARK INTERNAL MEDICINE, MEDICAL ASSOCIATES INC
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Dates
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Enumeration Date | 01/03/2007
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Last Update Date | 04/27/2011
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Provider Practice Location Address
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Address Line | 2970 5TH AVE SUITE #140
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City | SAN DIEGO
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State | CA
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Zip | 92103-5929
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Country | US
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Telephone | 619-260-3456
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Fax |
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Provider Business Mailing Address
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Address Line | 2970 5TH AVE SUITE #140
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City | SAN DIEGO
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State | CA
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Zip | 92103-5929
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Country | US
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Telephone | 619-260-3456
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY WOODALL
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Credential | M.D.
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Telephone | 619-260-3456
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A54031
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License Number State | CA
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