Healthcare Provider Details

I. General information

NPI: 1780841841
Provider Name (Legal Business Name): KESANAPALLI PEDIATRICS PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 FROST STREET SUITE 335
SAN DIEGO CA
92123-2771
US

IV. Provider business mailing address

7910 FROST STREET SUITE 335
SAN DIEGO CA
92123-2771
US

V. Phone/Fax

Practice location:
  • Phone: 858-576-8010
  • Fax: 858-576-7391
Mailing address:
  • Phone: 858-576-8010
  • Fax: 858-576-7391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA56064
License Number StateCA

VIII. Authorized Official

Name: DEEPTHI KESANAPALLI
Title or Position: CEO
Credential: M.D.
Phone: 858-576-8010