MEDICARE: DR. DAVID TODD WINE 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	207R00000X	Internal Medicine Physician	G45531	CA

General Provider Information

NPI Number	:	1811985542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID TODD WINE M.D.

Provider Business Mailing Address
First Line	:	2067 W VISTA WAY
Second Line	:	#200
City	:	VISTA
State	:	CA
Zip	:	92083-6031
Country	:	US
Telephone Number	:	760-726-2180
Fax Number	:	760-630-5716

Provider Business Practice Location Address
First Line	:	2067 W VISTA WAY
Second Line	:	#200
City	:	VISTA
State	:	CA
Zip	:	92083-6031
Country	:	US
Telephone Number	:	760-726-2180
Fax Number	:	760-726-9928

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

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	04/01/2020

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