Healthcare Provider Details

I. General information

NPI: 1972641736
Provider Name (Legal Business Name): EVERGREEN PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 SAN FELIPE RD #110
SAN JOSE CA
95135-1503
US

IV. Provider business mailing address

4205 SAN FELIPE RD #110
SAN JOSE CA
95135-1503
US

V. Phone/Fax

Practice location:
  • Phone: 408-238-8303
  • Fax: 408-238-8375
Mailing address:
  • Phone: 408-238-8303
  • Fax: 408-238-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA33613
License Number StateCA

VIII. Authorized Official

Name: DR. PRONOTI NIGAM
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 408-238-8303