Individual
AMIT DATE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD, MBA
Contact information
Practice address
5405 OBERLIN DR FL 2, SAN DIEGO, CA 92121-1700
(858) 909-0770
Mailing address
2674 COSTEBELLE DR, LA JOLLA, CA 92037-3516
(217) 417-5511
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
036126212
IL
207Y00000X
Otolaryngology Physician
125-049364
IL
207Y00000X
Otolaryngology Physician
Primary
C177918
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
IL2613
MEDICARE GROUP PTAN
IL
01
—
IL2613057
MEDICARE INDIVIDUAL PTAN
IL
Enumeration date
05/02/2007
Last updated
05/27/2022
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