Provider Demographics
NPI:1508967662
Name:GROSSMONT MEDICAL CLINIC A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GROSSMONT MEDICAL CLINIC A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-589-8626
Mailing Address - Street 1:PO BOX 261699
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92196-1699
Mailing Address - Country:US
Mailing Address - Phone:619-589-8626
Mailing Address - Fax:619-589-8864
Practice Address - Street 1:8851 CENTER DR
Practice Address - Street 2:SUITE 408
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3017
Practice Address - Country:US
Practice Address - Phone:619-589-8626
Practice Address - Fax:619-589-8864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0053450Medicaid
ZZZ34565ZOtherBLUE SHIELD
ZZZ34565ZOtherBLUE SHIELD