Basic Information
| Provider Information | |||||||||
| NPI: | 1104866318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRITCHEVSKY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | VA MEDICAL CENTER 3350 LA JOLLA VILLAGE DRIVE (912 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586423685 | ||||||||
| FaxNumber: | 8585527513 | ||||||||
| Practice Location | |||||||||
| Address1: | UCSD MEDICAL CENTER | ||||||||
| Address2: | 200 WEST ARBOR DRIVE MC 8201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921038201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586578540 | ||||||||
| FaxNumber: | 6195433183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2084N0400X | G38155 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 00G381550 | 05 | CA | MEDICAID |