Basic Information
| Provider Information | |||||||||
| NPI: | 1144253808 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ESCONDIDO INTERNAL MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 262160 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921962160 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 215 S HICKORY ST | ||||||||
| Address2: | STE 118 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920254359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604326644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHIANG | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7604326644 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZZZ66231Z | 01 | CA | BLUE SHIELD | OTHER |