Provider Demographics
NPI:1861014599
Name:SOUTHERN CALIFORNIA SURGICAL INC
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA SURGICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WANNARES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-898-0986
Mailing Address - Street 1:6415 REFLECTION DR APT 206
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3167
Mailing Address - Country:US
Mailing Address - Phone:508-898-0986
Mailing Address - Fax:619-330-2245
Practice Address - Street 1:8554 LA MESA BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-9558
Practice Address - Country:US
Practice Address - Phone:619-464-4469
Practice Address - Fax:619-713-0479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1851728141OtherMEDICARE
CA1851728141Medicaid