Provider Demographics
NPI:1568400455
Name:GATEWAY MEDICAL GROUP OF SAN DIEGO
Entity Type:Organization
Organization Name:GATEWAY MEDICAL GROUP OF SAN DIEGO
Other - Org Name:GATEWAY MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:SANZONE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-527-7700
Mailing Address - Street 1:286 EUCLID AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-3610
Mailing Address - Country:US
Mailing Address - Phone:619-527-7700
Mailing Address - Fax:619-527-3226
Practice Address - Street 1:752 MEDICAL CENTER CT
Practice Address - Street 2:SUITE 210
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6658
Practice Address - Country:US
Practice Address - Phone:619-527-7700
Practice Address - Fax:619-527-3226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW13278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0062450Medicaid
CAGR0062450Medicaid