1114271665 NPI number — SOUTHERN CALIFORNIA NEUROLOGY AND PSYCHIATRY

Table of content: (NPI 1114271665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114271665 NPI number — SOUTHERN CALIFORNIA NEUROLOGY AND PSYCHIATRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN CALIFORNIA NEUROLOGY AND PSYCHIATRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114271665
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1212 SAN DIEGUITO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENCINITAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92024-5115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-403-1701
Provider Business Mailing Address Fax Number:
619-810-2863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4275 EXECUTIVE SQ STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-1476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-403-1701
Provider Business Practice Location Address Fax Number:
619-810-2863
Provider Enumeration Date:
11/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
PANNA
Authorized Official Middle Name:
RAMANLAL
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
619-403-1701

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  C53290 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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