Provider Demographics
NPI:1669596557
Name:COLONIAL CORNER MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:COLONIAL CORNER MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:619-582-5105
Mailing Address - Street 1:4440 EUCLID AVE # C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4522
Mailing Address - Country:US
Mailing Address - Phone:619-582-5105
Mailing Address - Fax:619-582-5121
Practice Address - Street 1:4440 EUCLID AVE # C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4522
Practice Address - Country:US
Practice Address - Phone:619-582-5105
Practice Address - Fax:619-582-5121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86752174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0094010OtherMEDI-CAL
CAW17287OtherPTAN
CA4803435Medicare UPIN