Provider Demographics
NPI:1396780235
Name:SAN DIEGO PACIFIC ONCOLOGY AND HEMATOLOGY ASSOCIATES INC
Entity type:Organization
Organization Name:SAN DIEGO PACIFIC ONCOLOGY AND HEMATOLOGY ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSTRIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-309-6585
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:STE 830
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1224
Mailing Address - Country:US
Mailing Address - Phone:858-552-1410
Mailing Address - Fax:858-552-0929
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:STE 830
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-552-1410
Practice Address - Fax:858-552-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15618207RH0003X
CA20A8293207RH0003X
CAA50309207RH0003X
CAA52663207RH0003X
CAG34053207RH0003X
CAA69490207RX0202X
CAG64594207RX0202X
CAG48926207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003888074OtherNPI BESSUDO
CA1356300230OtherNPI SINCLAIR
AR1497727465OtherNPI MCCLAY
CA1164497855OtherNPI BANERJEE
AR1831162627OtherNPI EISENBERG
CA1174595144OtherNPI FRAKES
CA1205808920OtherNPI JUST
CA1205808920OtherNPI JUST
CA0804330001Medicare NSC
AR1497727465OtherNPI MCCLAY
CA1174595144OtherNPI FRAKES
CAG58718Medicare UPIN
ARC34008Medicare UPIN
AR1831162627OtherNPI EISENBERG
CAG72720Medicare UPIN
CAH70866Medicare UPIN