Provider Demographics
NPI:1265443444
Name:SAN DIEGO PEDIATRICS & FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:SAN DIEGO PEDIATRICS & FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:EDUARDO
Authorized Official - Last Name:EYZAGUIRRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-691-0001
Mailing Address - Street 1:401 H ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4321
Mailing Address - Country:US
Mailing Address - Phone:619-691-0001
Mailing Address - Fax:619-691-0111
Practice Address - Street 1:401 H ST
Practice Address - Street 2:SUITE #3
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4321
Practice Address - Country:US
Practice Address - Phone:619-691-0001
Practice Address - Fax:619-691-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42572208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty