Healthcare Provider Details

I. General information

NPI: 1871944983
Provider Name (Legal Business Name): DISHA ASHOK MISTRI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1295 BROADWAY SUITE 201
CHULA VISTA CA
91911-2982
US

IV. Provider business mailing address

1075 CAMINO DEL RIO S
SAN DIEGO CA
92108-3538
US

V. Phone/Fax

Practice location:
  • Phone: 888-743-7526
  • Fax: 619-291-0959
Mailing address:
  • Phone: 619-881-4500
  • Fax: 866-886-7824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95004476
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95094025
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2291990
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: