Healthcare Provider Details

I. General information

NPI: 1255990768
Provider Name (Legal Business Name): PRODIGY PSYCHIATRIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2019
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5791 CAPILANO DR
SAN JOSE CA
95138-2364
US

IV. Provider business mailing address

5791 CAPILANO DR
SAN JOSE CA
95138-2364
US

V. Phone/Fax

Practice location:
  • Phone: 408-630-1209
  • Fax:
Mailing address:
  • Phone: 510-875-7721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: BEETA R VERMA
Title or Position: PRESIDENT
Credential: MD
Phone: 510-875-7721