Healthcare Provider Details

I. General information

NPI: 1992249783
Provider Name (Legal Business Name): VAIJAYANTI S KOLDHEKAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 KELLWILL WAY
DUARTE CA
91010-3322
US

IV. Provider business mailing address

1212 KELLWILL WAY
DUARTE CA
91010-3322
US

V. Phone/Fax

Practice location:
  • Phone: 626-599-5222
  • Fax: 626-599-5274
Mailing address:
  • Phone: 626-599-5222
  • Fax: 626-599-5274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number3518
License Number StateCA

VIII. Authorized Official

Name: DR. VAIJAYANTI KOLDHEKAR
Title or Position: PHYSICIAN
Credential: MD
Phone: 626-303-2541