Provider Demographics
NPI:1154312775
Name:UCSD MED-CYTOGENETICS
Entity Type:Organization
Organization Name:UCSD MED-CYTOGENETICS
Other - Org Name:UCSD REGENTS OF CALIFORNIA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DELL'AQUILA PHD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:858-534-4308
Mailing Address - Street 1:9500 GILMAN DR
Mailing Address - Street 2:MAIL CODE 0639
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-0639
Mailing Address - Country:US
Mailing Address - Phone:858-534-4308
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DRIVE
Practice Address - Street 2:MAIL CODE 0639
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-0639
Practice Address - Country:US
Practice Address - Phone:858-534-4308
Practice Address - Fax:858-534-0269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0643070291U00000X
CACLF4717291U00000X
CACLIA05D0643070291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB43070FMedicaid
CAX558552Medicare ID - Type Unspecified