Basic Information
| Provider Information | |||||||||
| NPI: | 1578621199 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN DIEGO GASTROENTEROLOGY MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DENISON, GOODMAN, EPSTEN & HAYNES MEDICAL CORPORATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4060 4TH AVE | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921032116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192916064 | ||||||||
| FaxNumber: | 6192913078 | ||||||||
| Practice Location | |||||||||
| Address1: | 4060 4TH AVE | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921032116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192916064 | ||||||||
| FaxNumber: | 6192913078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 05/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | EPSTEN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6192916064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | G46179 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.