Provider Demographics
NPI:1669661815
Name:UNIVERSITY OF CALIFORNIA, SAN DIEGO
Entity Type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA, SAN DIEGO
Other - Org Name:MEDICAL GENETICS
Other - Org Type:Other Name
Authorized Official - Title/Position:LEAD GENETIC COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIBUK
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CGC
Authorized Official - Phone:858-657-7212
Mailing Address - Street 1:9310 CAMPUS POINT DR STE B
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1300
Mailing Address - Country:US
Mailing Address - Phone:858-657-7206
Mailing Address - Fax:858-657-7201
Practice Address - Street 1:9350 CAMPUS POINT DR STE 2D
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1300
Practice Address - Country:US
Practice Address - Phone:858-657-7206
Practice Address - Fax:858-657-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QG0250X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QG0250XAmbulatory Health Care FacilitiesClinic/CenterGenetics