Provider Demographics
NPI:1841438413
Name:RICHARD L BUCCIGROSS MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:RICHARD L BUCCIGROSS MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:BUCCIGROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-565-0900
Mailing Address - Street 1:4550 KEARNY VILLA RD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1578
Mailing Address - Country:US
Mailing Address - Phone:858-565-0900
Mailing Address - Fax:
Practice Address - Street 1:4550 KEARNY VILLA RD
Practice Address - Street 2:SUITE 214
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1578
Practice Address - Country:US
Practice Address - Phone:858-565-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG311852084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G311850Medicaid
CA00G311850Medicaid
CAG31185Medicare PIN