Healthcare Provider Details

I. General information

NPI: 1790830511
Provider Name (Legal Business Name): SUDHA AMATYA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUDHA SHRESTHA AMATYA

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5454 EL CAJON BLVD
SAN DIEGO CA
92115-3621
US

IV. Provider business mailing address

823 GATEWAY CENTER WAY
SAN DIEGO CA
92102
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2400
  • Fax:
Mailing address:
  • Phone: 619-515-2300
  • Fax: 619-906-4564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA51563
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number35087784
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: