Provider Demographics
NPI:1578621199
Name:SAN DIEGO GASTROENTEROLOGY MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:SAN DIEGO GASTROENTEROLOGY MEDICAL ASSOCIATES
Other - Org Name:DENISON, GOODMAN, EPSTEN & HAYNES MEDICAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:EPSTEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:619-291-6064
Mailing Address - Street 1:4060 4TH AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-291-6064
Mailing Address - Fax:619-291-3078
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-291-6064
Practice Address - Fax:619-291-3078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46179207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI08640Medicare UPIN
CA1699917096Medicare NSC
CAA92628Medicare UPIN
CAE23408Medicare UPIN
CAA111638Medicare PIN
CA21263Medicare PIN
CAI14215Medicare UPIN
CAW3533Medicare ID - Type Unspecified
CAA116352Medicare PIN