Healthcare Provider Details

I. General information

NPI: 1629062005
Provider Name (Legal Business Name): KRISHAN KUMAR VASHISTHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27141 HIDAWAY AVE STE 105
CANYON COUNTRY CA
91351-4131
US

IV. Provider business mailing address

27141 HIDAWAY AVE STE 105
CANYON COUNTRY CA
91351-4131
US

V. Phone/Fax

Practice location:
  • Phone: 661-251-4783
  • Fax: 661-251-8245
Mailing address:
  • Phone: 661-251-4783
  • Fax: 661-251-8245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA31642
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberA31642
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: