Provider Demographics
NPI:1104038587
Name:SPONDYLOS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SPONDYLOS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:VAN DAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-587-0700
Mailing Address - Street 1:4130 LA JOLLA VILLAGE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9121
Mailing Address - Country:US
Mailing Address - Phone:858-587-0700
Mailing Address - Fax:858-587-0401
Practice Address - Street 1:4130 LA JOLLA VILLAGE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9121
Practice Address - Country:US
Practice Address - Phone:858-587-0700
Practice Address - Fax:858-587-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35628207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty