Healthcare Provider Details

I. General information

NPI: 1144673518
Provider Name (Legal Business Name): NISHA WADHWA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 11/22/2021
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25965 NORMANDIE AVE
HARBOR CITY CA
90710-3416
US

IV. Provider business mailing address

46 VIA MALONA
RANCHO PALOS VERDES CA
90275-4882
US

V. Phone/Fax

Practice location:
  • Phone: 310-467-9908
  • Fax:
Mailing address:
  • Phone: 310-467-9908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA152354
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: