Provider Demographics
NPI:1033393467
Name:BRUCE SAHBA MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BRUCE SAHBA MD A MEDICAL CORPORATION
Other - Org Name:BRUCE SAHBA MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:FLAKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-660-2770
Mailing Address - Street 1:3865 CLAIREMONT DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5831
Mailing Address - Country:US
Mailing Address - Phone:858-272-2300
Mailing Address - Fax:858-272-2340
Practice Address - Street 1:3865 CLAIREMONT DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5831
Practice Address - Country:US
Practice Address - Phone:858-272-2300
Practice Address - Fax:858-272-2340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31591174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0081310Medicaid
CAW14230Medicare PIN
CAGR0081310Medicaid
CAA84234Medicare UPIN
W14230Medicare PIN