Provider Demographics
NPI:1972659761
Name:ONDRUSEK, MICHAEL GENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GENE
Last Name:ONDRUSEK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2329 LORING ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-2346
Mailing Address - Country:US
Mailing Address - Phone:858-273-5657
Mailing Address - Fax:858-273-5657
Practice Address - Street 1:4550 KEARNY VILLA RD
Practice Address - Street 2:STE 109
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1574
Practice Address - Country:US
Practice Address - Phone:858-455-8323
Practice Address - Fax:858-273-5657
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8461103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA202539046Medicare UPIN
CACP8461Medicare ID - Type UnspecifiedMEDICARE ID NUMBER