Provider Demographics
NPI:1952637050
Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-470-4321
Mailing Address - Street 1:FILE NO 54826
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4826
Mailing Address - Country:US
Mailing Address - Phone:562-809-3525
Mailing Address - Fax:562-468-0347
Practice Address - Street 1:477 N EL CAMINO REAL
Practice Address - Street 2:BUILDING D, SUITE 204
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1328
Practice Address - Country:US
Practice Address - Phone:858-552-0600
Practice Address - Fax:858-552-0604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952637050Medicaid
CA1952637050Medicaid