Provider Demographics
NPI:1134713704
Name:PRESTIGE ORTHOPAEDICS AND SPORTS MEDICINE, INC.
Entity type:Organization
Organization Name:PRESTIGE ORTHOPAEDICS AND SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:URBAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-705-6130
Mailing Address - Street 1:11939 RANCHO BERNARDO RD STE 115
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2073
Mailing Address - Country:US
Mailing Address - Phone:858-705-6130
Mailing Address - Fax:858-400-4080
Practice Address - Street 1:11939 RANCHO BERNARDO RD STE 115
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2073
Practice Address - Country:US
Practice Address - Phone:858-705-6130
Practice Address - Fax:858-400-4080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-24
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1376834572OtherNPI TYPE I