Provider Demographics
NPI:1881874824
Name:DR. BARRY JULIAN BROOMBERG M.D.
Entity type:Organization
Organization Name:DR. BARRY JULIAN BROOMBERG M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:JULIAN
Authorized Official - Last Name:BROOMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:C41796
Authorized Official - Phone:858-454-7157
Mailing Address - Street 1:6515 LA JOLLA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-6066
Mailing Address - Country:US
Mailing Address - Phone:858-454-7157
Mailing Address - Fax:858-454-6460
Practice Address - Street 1:6515 LA JOLLA BLVD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-6066
Practice Address - Country:US
Practice Address - Phone:858-454-7157
Practice Address - Fax:858-454-6460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18195Medicare PIN