Provider Demographics
NPI:1457494361
Name:SAN DIEGO FERTILITY CENTER MEDICAL GROUP,INC
Entity Type:Organization
Organization Name:SAN DIEGO FERTILITY CENTER MEDICAL GROUP,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDOLAH
Authorized Official - Suffix:
Authorized Official - Credentials:RN,MBA
Authorized Official - Phone:858-720-3177
Mailing Address - Street 1:11425 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2045
Mailing Address - Country:US
Mailing Address - Phone:858-794-6363
Mailing Address - Fax:858-794-6360
Practice Address - Street 1:11425 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2045
Practice Address - Country:US
Practice Address - Phone:858-794-6363
Practice Address - Fax:858-794-6360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Single Specialty