# AGEREVERSALMD.COM A PROFESSIONAL CORPORATION

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1194450023
- **Authorized official:** PHILLIP MARK MILGRAM MD (CEO)
- **Authorized official phone:** (858) 776-0544

## Contact information

- **Practice address:** 3252 HOLIDAY CT STE 211, LA JOLLA, CA 92037-0027
- **Practice address phone:** (858) 776-0544
- **Practice address fax:** (760) 692-4411
- **Mailing address:** 444 N EL CAMINO REAL SPC 123, ENCINITAS, CA 92024-1317
- **Mailing address phone:** (858) 776-0544
- **Mailing address fax:** (760) 692-4411

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207VG0400X | Gynecology Physician | — | NULL | — |
| 207VG0400X | Gynecology Physician | — | — | — |
| 251K00000X | Public Health or Welfare Agency | — | NULL | Yes |
| 261QP2300X | Primary Care Clinic/Center | — | NULL | — |
| 261QP3300X | Pain Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 07/24/2022
- **Last updated:** 07/24/2022