Healthcare Provider Details

I. General information

NPI: 1619262664
Provider Name (Legal Business Name): ASHVIN B SHENOY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

292 EUCLID AVE SUITE 220
SAN DIEGO CA
92114-3629
US

IV. Provider business mailing address

3860 CALLE FORTUNADA SUITE 200
SAN DIEGO CA
92123-4802
US

V. Phone/Fax

Practice location:
  • Phone: 619-262-8624
  • Fax: 619-262-6639
Mailing address:
  • Phone: 858-636-4300
  • Fax: 858-636-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA123017
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: