Provider Demographics
NPI:1083625016
Name:SAN DIEGO HEART & MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:SAN DIEGO HEART & MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLEID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-274-2560
Mailing Address - Street 1:3660 CLAIREMONT DR
Mailing Address - Street 2:STE 6
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117
Mailing Address - Country:US
Mailing Address - Phone:858-274-2560
Mailing Address - Fax:858-274-1610
Practice Address - Street 1:3660 CLAIREMONT DR
Practice Address - Street 2:STE 6
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117
Practice Address - Country:US
Practice Address - Phone:858-274-2560
Practice Address - Fax:858-274-1610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20415207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA90639Medicare UPIN
CAWR5269Medicare PIN