Healthcare Provider Details

I. General information

NPI: 1487843454
Provider Name (Legal Business Name): SRIVIDYA A MAHENDRAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 UNIVERISITY AVENUE SUITE 150 SAN DIEGO FAMILY CARE, DBA MID-CITY COMMUNITY CLINIC-PE
SAN DIEGO CA
92105-1601
US

IV. Provider business mailing address

4305 UNIVERSITY AVENUE SUITE 150 SAN DIEGO FAMILY CARE, DBA MID-CITY COMMUNITY CLINIC-PE
SAN DIEGO CA
92105-1601
US

V. Phone/Fax

Practice location:
  • Phone: 619-280-2058
  • Fax: 858-633-4682
Mailing address:
  • Phone: 619-280-2058
  • Fax: 858-633-4682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA92173
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: