Provider Demographics
NPI:1093885824
Name:RICH, JEREMY (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:RICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3855 HEALTH SCIENCES DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-0001
Practice Address - Country:US
Practice Address - Phone:858-822-6100
Practice Address - Fax:858-657-1274
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1517802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891129XMedicare ID - Type Unspecified
NC2252177Medicare ID - Type Unspecified
G67494Medicare ID - Type Unspecified