Provider Demographics
NPI:1003996216
Name:PRESIDIO MEDICAL GROUP INC
Entity Type:Organization
Organization Name:PRESIDIO MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-272-0022
Mailing Address - Street 1:4440 LAMONT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4560
Mailing Address - Country:US
Mailing Address - Phone:858-270-7633
Mailing Address - Fax:858-270-7692
Practice Address - Street 1:4440 LAMONT ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4560
Practice Address - Country:US
Practice Address - Phone:858-270-7633
Practice Address - Fax:858-270-7692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14204Medicare ID - Type Unspecified