Basic Information
| Provider Information | |||||||||
| NPI: | 1619431244 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9400 GILMAN DR MAIL CODE 7970 PROVIDER ENROLLMENT | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920930021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582496758 | ||||||||
| FaxNumber: | 6195433183 | ||||||||
| Practice Location | |||||||||
| Address1: | 7710 EL CAMINO REAL STE F | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920098506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194886900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2019 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO, UC SAN DIEGO CLINICAL PRACTICE | ||||||||
| AuthorizedOfficialTelephone: | 6195438300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.