Provider Demographics
NPI:1811942139
Name:LA JOLLA UROLOGY
Entity type:Organization
Organization Name:LA JOLLA UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:MAHOMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-458-0099
Mailing Address - Street 1:PO BOX 33865
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3865
Mailing Address - Country:US
Mailing Address - Phone:858-888-7700
Mailing Address - Fax:858-888-7721
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:#421
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1223
Practice Address - Country:US
Practice Address - Phone:858-458-0099
Practice Address - Fax:858-458-9330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14188Medicare ID - Type Unspecified