Basic Information
| Provider Information | |||||||||
| NPI: | 1003059700 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN DIEGO HOSPITAL BASED PHYSICIAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EL CENTRO HOSPITAL BASED PHYSICIAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11438 STOCKWOOD CV | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921314254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584950971 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1415 ROSS AVE | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603397100 | ||||||||
| FaxNumber: | 7603397389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2009 | ||||||||
| LastUpdateDate: | 04/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | RAMIREZ | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8584950971 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A60709 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.