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Organization
AGEREVERSALMD.COM A PROFESSIONAL CORPORATION
Active
Organization
AGEREVERSALMD.COM A PROFESSIONAL CORPORATION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PHILLIP MARK MILGRAM MD (CEO)
(858) 776-0544
Entity
Organization
Contact information
Practice address
3252 HOLIDAY CT STE 211, LA JOLLA, CA 92037-0027
(858) 776-0544
(760) 692-4411
Mailing address
444 N EL CAMINO REAL SPC 123, ENCINITAS, CA 92024-1317
(858) 776-0544
(760) 692-4411
Taxonomy
Speciality
Code
Description
License number
State
207VG0400X
Gynecology Physician
—
NULL
207VG0400X
Gynecology Physician
—
—
251K00000X
Public Health or Welfare Agency
Primary
—
NULL
261QP2300X
Primary Care Clinic/Center
—
NULL
261QP3300X
Pain Clinic/Center
—
NULL
Other
Enumeration date
07/24/2022
Last updated
07/24/2022
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