Provider Demographics
NPI:1679509962
Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA UCSD HEAD AND NECK SURGERY
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA UCSD HEAD AND NECK SURGERY
Other - Org Name:UCSD OTOLARYNGOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF, DIVISION OF OTOLARYNGOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-543-3604
Mailing Address - Street 1:PO BOX 513599
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3599
Mailing Address - Country:US
Mailing Address - Phone:858-974-9766
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9001
Practice Address - Country:US
Practice Address - Phone:858-543-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0057990Medicaid
CAW12211Medicare ID - Type Unspecified