Provider Demographics
NPI:1407817448
Name:SAN DIEGO ORTHOPAEDIC ASSOCIATES MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SAN DIEGO ORTHOPAEDIC ASSOCIATES MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SELF
Authorized Official - Prefix:
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:760-693-6520
Mailing Address - Street 1:7257 N CRIMSON SKY WAY
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86315-3108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2121
Practice Address - Country:US
Practice Address - Phone:619-299-8500
Practice Address - Fax:619-297-1443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W758Medicare PIN
0643090001Medicare NSC