Basic Information
| Provider Information | |||||||||
| NPI: | 1346628310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDAURRAZAGA | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 GATEWAY CENTER WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4094 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921032143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152545 | ||||||||
| FaxNumber: | 6195019645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2015 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | A169207 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.