Provider Demographics
NPI:1376631333
Name:RANDAL J. VECCHIONE M.D., INC., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RANDAL J. VECCHIONE M.D., INC., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:VECCHIONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-234-1674
Mailing Address - Street 1:2542 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6537
Mailing Address - Country:US
Mailing Address - Phone:619-234-1674
Mailing Address - Fax:619-234-1680
Practice Address - Street 1:2542 2ND AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6537
Practice Address - Country:US
Practice Address - Phone:619-234-1674
Practice Address - Fax:619-234-1680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34154208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA27395Medicare UPIN
CAA34154Medicare ID - Type Unspecified