Provider Demographics
NPI:1073707584
Name:SAN DIEGO NEUROSURGERY AND SPINE INSTITUTE
Entity Type:Organization
Organization Name:SAN DIEGO NEUROSURGERY AND SPINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:TIPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-634-5900
Mailing Address - Street 1:561 SAXONY PLACE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024
Mailing Address - Country:US
Mailing Address - Phone:760-634-5900
Mailing Address - Fax:760-634-5905
Practice Address - Street 1:450 4TH AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4426
Practice Address - Country:US
Practice Address - Phone:760-634-5900
Practice Address - Fax:760-634-5905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68540207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W15450Medicare PIN