Healthcare Provider Details

I. General information

NPI: 1891812962
Provider Name (Legal Business Name): NISHA J BUNKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE SUITE #410
LA JOLLA CA
92037-1224
US

IV. Provider business mailing address

9850 GENESEE AVE SUITE #410
SAN DIEGO CA
92121
US

V. Phone/Fax

Practice location:
  • Phone: 858-550-0330
  • Fax: 858-550-0676
Mailing address:
  • Phone: 858-550-0330
  • Fax: 858-550-0676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA101022
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01063562A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: