Agereversalmd.Com a Professional Corporation

Primary specialty

Public Health or Welfare AgencyTaxonomy code 251K00000X

Legal business name

AGEREVERSALMD.COM A PROFESSIONAL CORPORATION

Practice address

3252 Holiday CT Ste 211
La Jolla, CA 92037-0027

Phone

(858) 776-0544

Fax

(760) 692-4411

NPI assigned

Jul 24, 2022

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Phillip Mark Milgram, MDNPI 1285737569

Title

Ceo

Phone

(858) 776-0544

Specialties & licenses 4

Addresses

Other identifiers 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Phillip Mark Milgram, M.D.

  • Public Health & General Preventive Medicine Physician
  • La Jolla, CA
  • NPI 1285737569
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1658620800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658620800000",
    "number": "1194450023",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "444 N EL CAMINO REAL SPC 123",
            "city": "ENCINITAS",
            "state": "CA",
            "postal_code": "920241317",
            "telephone_number": "858-776-0544",
            "fax_number": "760-692-4411"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3252 HOLIDAY CT STE 211",
            "city": "LA JOLLA",
            "state": "CA",
            "postal_code": "920370027",
            "telephone_number": "858-776-0544",
            "fax_number": "760-692-4411"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1207 Carlsbad Village Dr Ste Q",
            "address_purpose": "LOCATION",
            "city": "Carlsbad",
            "state": "CA",
            "postal_code": "920081958",
            "country_code": "US",
            "telephone_number": "760-944-9200",
            "fax_number": "760-692-4411",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "AGEREVERSALMD.COM A PROFESSIONAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-07-24",
        "last_updated": "2022-07-24",
        "certification_date": "2022-07-24",
        "status": "A",
        "authorized_official_last_name": "MILGRAM",
        "authorized_official_first_name": "PHILLIP",
        "authorized_official_middle_name": "MARK",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "858-776-0544",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207VG0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology, Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "251K00000X",
            "taxonomy_group": "",
            "desc": "Public Health or Welfare",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP3300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Pain",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INDIVIDUAL NPI",
            "identifier": "1285737569",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Anahita Afshar
• Natalie A Afshari, M.D.
• Rouben Vahan Aftandelians, MD
• Sanjay Kumar Agarwal, M.D.
• Michael Jean Olivier Agbassi, PHARM D
• Marlane Agriesti, LMFT
• Lesly Giselle Aguilar Tabora
• Troy Aguilera, MPT
• Farshad M Ahadian, M.D.
• Aaron Isaac Ahdoot

• All providers in La Jolla, CA
• Public Health or Welfare Agency in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 24, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.