Provider Demographics
NPI:1639148828
Name:TEGUH, COLLIN (DO)
Entity Type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:
Last Name:TEGUH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1212
Mailing Address - Country:US
Mailing Address - Phone:619-281-8988
Mailing Address - Fax:619-281-0194
Practice Address - Street 1:2045 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-1212
Practice Address - Country:US
Practice Address - Phone:619-281-8988
Practice Address - Fax:619-281-0194
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX63321Medicaid
CAF58653Medicare UPIN
CA20A6332Medicare ID - Type Unspecified
CA00AX63321Medicaid