Provider Demographics
NPI:1073677811
Name:LA JOLLA SPINE INSTITUTE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:LA JOLLA SPINE INSTITUTE MEDICAL GROUP, INC.
Other - Org Name:SPINE INSTITUTE OF SAN DIEGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAISZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-265-7912
Mailing Address - Street 1:6719 ALVARADO ROAD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120
Mailing Address - Country:US
Mailing Address - Phone:619-265-7912
Mailing Address - Fax:619-265-7922
Practice Address - Street 1:6719 ALVARADO RD.
Practice Address - Street 2:SUITE 308
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120
Practice Address - Country:US
Practice Address - Phone:619-265-7912
Practice Address - Fax:619-265-7922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA88341OtherLICENSE NUMBER
CAA111653OtherMEDICAL BOARD OF CA
CAA64323OtherSTATE LICENSE
CAG74016OtherLICENSE NUMBER
CAI25203Medicare UPIN
CAW15062Medicare UPIN
CAG37814Medicare UPIN