Organization
COLONIAL CORNER MEDICAL GROUP, INC.
Active
Other names
Colonial Corner Medical Group, Inc.
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ELIZABETH DAVID I (FINANCE MANAGER)
(619) 582-5105
Entity
Organization
Contact information
Practice address
4440 EUCLID AVE # C, SAN DIEGO, CA 92115-4522
(619) 582-5105
(619) 582-5121
Mailing address
4440 EUCLID AVE # C, SAN DIEGO, CA 92115-4522
(619) 582-5105
(619) 582-5121
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
G86752
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
GR0094010
MEDI-CAL
CA
01
—
W17287
PTAN
CA
Enumeration date
03/18/2007
Last updated
07/21/2022
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