Healthcare Provider Details

I. General information

NPI: 1073142675
Provider Name (Legal Business Name): NEIL MAITRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9898 GENESEE AVE
LA JOLLA CA
92037-1205
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-824-5333
  • Fax:
Mailing address:
  • Phone: 858-824-5333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA186167
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: