Provider Demographics
NPI:1447346192
Name:SPECKART, PAUL FREDRICK (MD, MFACP)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:FREDRICK
Last Name:SPECKART
Suffix:
Gender:M
Credentials:MD, MFACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1323
Mailing Address - Country:US
Mailing Address - Phone:619-293-3021
Mailing Address - Fax:
Practice Address - Street 1:3260 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5616
Practice Address - Country:US
Practice Address - Phone:619-297-3737
Practice Address - Fax:619-297-0443
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC31776207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA92585978OtherCHAMPUS
CAC31776OtherBLUE CROSS
CA00C317760Medicaid
CA31776OtherHMO
CA00C317660OtherBLUE SHIELD
CAC31776OtherPPO/COMM
WC31776AMedicare PIN
CAC31776OtherPPO/COMM