Provider Demographics
NPI:1578965471
Name:UC SAN DIEGO FOUNDATION
Entity Type:Organization
Organization Name:UC SAN DIEGO FOUNDATION
Other - Org Name:UCSD STUDENT RUN FREE CLINIC PROJECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNNY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-534-6160
Mailing Address - Street 1:9500 GILMAN DR
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-0696
Mailing Address - Country:US
Mailing Address - Phone:858-534-6160
Mailing Address - Fax:858-822-3990
Practice Address - Street 1:1420 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3103
Practice Address - Country:US
Practice Address - Phone:858-534-6160
Practice Address - Fax:858-822-3990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UC SAN DIEGO FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service