Provider Demographics
NPI:1255717377
Name:UCSD DEPARTMENT OF PEDIATRICS
Entity type:Organization
Organization Name:UCSD DEPARTMENT OF PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION CHIEF
Authorized Official - Prefix:PROF
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LYONS
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-246-1738
Mailing Address - Street 1:5531 LADYBIRD LN
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7721
Mailing Address - Country:US
Mailing Address - Phone:858-761-1308
Mailing Address - Fax:
Practice Address - Street 1:7910 FORST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-246-1738
Practice Address - Fax:858-246-1793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASFP000030282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren