Provider Demographics
NPI:1073699971
Name:DIGESTIVE DISEASE ASSOCIATES, INC
Entity Type:Organization
Organization Name:DIGESTIVE DISEASE ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TADDESEE
Authorized Official - Middle Name:TEFERI
Authorized Official - Last Name:DESTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-266-3332
Mailing Address - Street 1:292 EUCLID AVE
Mailing Address - Street 2:STE 115
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114
Mailing Address - Country:US
Mailing Address - Phone:619-266-3332
Mailing Address - Fax:619-266-6000
Practice Address - Street 1:292 EUCLID AVE
Practice Address - Street 2:STE 115
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114
Practice Address - Country:US
Practice Address - Phone:619-266-3332
Practice Address - Fax:619-266-6000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49164174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A491640Medicaid
CAF27762Medicare UPIN
CAW16810Medicare ID - Type UnspecifiedM/CARE GP ID