Healthcare Provider Details

I. General information

NPI: 1912100546
Provider Name (Legal Business Name): PRIYA SHANTHI HARDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2007
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FAIRMOUNT AVE STE 415
PASADENA CA
91105-3150
US

IV. Provider business mailing address

800 FAIRMOUNT AVE STE 415
PASADENA CA
91105-3150
US

V. Phone/Fax

Practice location:
  • Phone: 626-449-8440
  • Fax:
Mailing address:
  • Phone: 626-449-8440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA112800
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: