Provider Demographics
NPI:1457330607
Name:MARDACH, REBECCA (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:MARDACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:MARDACH-VERDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3020 CHILDRENS WAY # MC5003
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-309-6300
Mailing Address - Fax:
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
Practice Address - Country:US
Practice Address - Phone:619-543-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-14
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45110207SG0202X, 208000000X, 207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics