Provider Demographics
NPI:1275796419
Name:DIMMOCK, DAVID P (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
Last Name:DIMMOCK
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 1:3030 CHILDRENS WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4232
Mailing Address - Country:US
Mailing Address - Phone:800-788-9029
Mailing Address - Fax:858-966-8092
Practice Address - Street 1:3030 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4232
Practice Address - Country:US
Practice Address - Phone:800-788-9029
Practice Address - Fax:858-966-8092
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC146669207SG0201X, 208000000X, 207SG0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1275796419Medicaid
WI116673601Medicare PIN