Provider Demographics
NPI:1013035716
Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Other - Org Name:UCSD PEDIATRIC AND ADOLESCENT ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIVISION CHIEF OF GENERAL ACADEMIC
Authorized Official - Prefix:
Authorized Official - First Name:BRETTEN
Authorized Official - Middle Name:DRAKE
Authorized Official - Last Name:PICKERING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-496-4827
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4800
Mailing Address - Country:US
Mailing Address - Phone:858-502-1135
Mailing Address - Fax:858-636-4319
Practice Address - Street 1:7910 FROST STREET
Practice Address - Street 2:STE 350
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2771
Practice Address - Country:US
Practice Address - Phone:858-496-4800
Practice Address - Fax:858-496-4850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0105540Medicaid
CAZZZ69468ZOtherBLUE SHIELD