Provider Demographics
NPI:1780128256
Name:ADVANCED MD MEDICAL GROUP INC
Entity type:Organization
Organization Name:ADVANCED MD MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:KANCILIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-345-4887
Mailing Address - Street 1:235 W WASHINGTON AVE
Mailing Address - Street 2:A55
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-2634
Mailing Address - Country:US
Mailing Address - Phone:858-345-4887
Mailing Address - Fax:
Practice Address - Street 1:2878 CAMINO DEL RIO S STE 404
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3848
Practice Address - Country:US
Practice Address - Phone:858-345-4887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-18
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87969208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty