Provider Demographics
NPI:1609941806
Name:GARGAS, JESSIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:
Last Name:GARGAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 CHILDRENS WAY
Mailing Address - Street 2:MAIL CODE 5064
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-576-1700
Mailing Address - Fax:858-966-6728
Practice Address - Street 1:3020 CHILDRENS WAY
Practice Address - Street 2:MAIL CODE 5064
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-576-1700
Practice Address - Fax:858-966-6728
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85447208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A854470Medicaid
I31569Medicare UPIN
CAI31569Medicare UPIN
CAWA85447AMedicare ID - Type Unspecified