Provider Demographics
NPI:1306014402
Name:PERRI L WITTGROVE MD
Entity Type:Organization
Organization Name:PERRI L WITTGROVE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:WITTGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-326-0700
Mailing Address - Street 1:6719 ALVARADO RD
Mailing Address - Street 2:#302
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5270
Mailing Address - Country:US
Mailing Address - Phone:619-326-0700
Mailing Address - Fax:619-326-0703
Practice Address - Street 1:6719 ALVARADO RD
Practice Address - Street 2:#302
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5270
Practice Address - Country:US
Practice Address - Phone:619-326-0700
Practice Address - Fax:619-326-0703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56550207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14550Medicare PIN