MEDICARE: SAN DIEGO PREP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1144916248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN DIEGO PREP INC

Provider Business Mailing Address
First Line	:	1665 UNION ST STE A
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2906
Country	:	US
Telephone Number	:	559-579-8343
Fax Number	:	619-373-9206

Provider Business Practice Location Address
First Line	:	1665 UNION ST STE A
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2906
Country	:	US
Telephone Number	:	619-736-1772
Fax Number	:	619-373-9206

Authorized Official
Title or Position	:	COO
Name	:	ANTHONY FAM
Credential	:	MD
Telephone Number	:	559-579-8343

Provider Enumeration Date	:	04/12/2023
Last Update Date	:	04/12/2023

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Directions to “SAN DIEGO PREP INC ” Practice Location

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