Provider Demographics
NPI:1912917345
Name:IGNACIO, KATHLYN R (MD)
Entity Type:Individual
Prefix:
First Name:KATHLYN
Middle Name:R
Last Name:IGNACIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 GENESEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4219
Mailing Address - Country:US
Mailing Address - Phone:858-616-8400
Mailing Address - Fax:858-569-0741
Practice Address - Street 1:2020 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4219
Practice Address - Country:US
Practice Address - Phone:858-616-8400
Practice Address - Fax:858-569-0741
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46520207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A465200Medicaid
CAF11562Medicare UPIN
CA00A465200Medicaid