Provider Demographics
NPI:1639398613
Name:SHADOWRIDGE MEDICAL GROUP
Entity Type:Organization
Organization Name:SHADOWRIDGE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:WINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-727-6920
Mailing Address - Street 1:1680 S MELROSE DR STE 105
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-5472
Mailing Address - Country:US
Mailing Address - Phone:760-727-6920
Mailing Address - Fax:760-727-3368
Practice Address - Street 1:1680 S MELROSE DR STE 105
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-5472
Practice Address - Country:US
Practice Address - Phone:760-727-6920
Practice Address - Fax:760-727-3368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG045531174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50078Medicare UPIN