MEDICARE: DR. LUCKVIN PONSINGH MANUEL M.D.

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	2084P0804X	Child & Adolescent Psychiatry Physician	A89173	CA
2	2084P0800X	Psychiatry Physician	A89173	CA

General Provider Information

NPI Number	:	1699857813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUCKVIN PONSINGH MANUEL M.D.

Provider Business Mailing Address
First Line	:	1260 MORENA BLVD STE 100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-3850
Country	:	US
Telephone Number	:	619-398-0355
Fax Number	:	619-398-0350

Provider Business Practice Location Address
First Line	:	1260 MORENA BLVD STE 100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-3850
Country	:	US
Telephone Number	:	619-398-0355
Fax Number	:	619-398-0350

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	03/15/2011

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