Provider Demographics
NPI:1043352651
Name:LA JOLLA PERSONAL PHYSICIANS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:LA JOLLA PERSONAL PHYSICIANS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KWI
Authorized Official - Middle Name:
Authorized Official - Last Name:BULOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-587-4773
Mailing Address - Street 1:9834 GENESEE AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1216
Mailing Address - Country:US
Mailing Address - Phone:858-587-4773
Mailing Address - Fax:858-587-4785
Practice Address - Street 1:9834 GENESEE AVE STE 400
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1216
Practice Address - Country:US
Practice Address - Phone:858-587-4773
Practice Address - Fax:858-587-4785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56674207R00000X
CAG57573207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty