Healthcare Provider Details

I. General information

NPI: 1164497855
Provider Name (Legal Business Name): PUSHPENDU BANERJEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE STE 560
LA JOLLA CA
92037-1229
US

IV. Provider business mailing address

PO BOX 25100
FRESNO CA
93729-5100
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-1410
  • Fax: 858-552-0929
Mailing address:
  • Phone: 559-326-1222
  • Fax: 559-326-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberA69490
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: