Basic Information
| Provider Information | |||||||||
| NPI: | 1104842129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERRICONE | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 W ARBOR DR | ||||||||
| Address2: | MAIL CODE 8892 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921039001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195437777 | ||||||||
| FaxNumber: | 6195432652 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 W ARBOR DR | ||||||||
| Address2: | MAIL CODE 8892 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921039001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195437777 | ||||||||
| FaxNumber: | 6195432652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 05/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | G65464 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | G65464 | CA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 00G654640 | 05 | CA | MEDICAID |