Basic Information
| Provider Information | |||||||||
| NPI: | 1407210537 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOLODGE | ||||||||
| FirstName: | GAVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4445 EASTGATE MALL | ||||||||
| Address2: | STE 105 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583579450 | ||||||||
| FaxNumber: | 8584126376 | ||||||||
| Practice Location | |||||||||
| Address1: | 9339 GENESEE AVE | ||||||||
| Address2: | STE 150 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921212144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583579477 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 20A18281 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.