Provider Demographics
NPI:1003968009
Name:AMUNDSON, STANLEY A (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:A
Last Name:AMUNDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4077 5TH AVE
Mailing Address - Street 2:MER 35
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2105
Mailing Address - Country:US
Mailing Address - Phone:619-260-0770
Mailing Address - Fax:
Practice Address - Street 1:4022 FIFTH AVENUE
Practice Address - Street 2:MERCY CLINIC
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-8102
Practice Address - Country:US
Practice Address - Phone:619-260-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN