Healthcare Provider Details

I. General information

NPI: 1275892754
Provider Name (Legal Business Name): SRIVIDYA NARASIMHAN SAMPATH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SRIVIDYA NARASIMHAN

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4725 MARKET ST
SAN DIEGO CA
92102-4715
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA132576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: