Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | A49419 | CA |
Y | 207QS0010X | Family Doctor - Sports Medicine | A49419 | CA |
NPI | 1215900683 |
---|---|
Provider Name | Grant Barrie Neifeld |
First Address | San Diego, CA 92130-1414 |
Second Address | La Mesa, CA 91942-3134 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2006 |
Last Update Date | 08/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D32889 | (02) | CA |
ZZZ36915Z | (05) | CA |