Provider Demographics
NPI:1801968730
Name:SAN DIEGO UROLOGICAL MEDICAL GROUP
Entity type:Organization
Organization Name:SAN DIEGO UROLOGICAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO & OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALTON
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-697-2456
Mailing Address - Street 1:8851 CENTER DR
Mailing Address - Street 2:STE 501
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3058
Mailing Address - Country:US
Mailing Address - Phone:619-697-2456
Mailing Address - Fax:619-697-2494
Practice Address - Street 1:8851 CENTER DR
Practice Address - Street 2:STE 501
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3058
Practice Address - Country:US
Practice Address - Phone:619-697-2456
Practice Address - Fax:619-697-2494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ49499ZMedicaid
CAZZZ49499ZMedicaid