Healthcare Provider Details

I. General information

NPI: 1558313916
Provider Name (Legal Business Name): TISSA R HATA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST ARBOR DRIVE MC 8201 UCSD MEDICAL CENTER
SAN DIEGO CA
92103-8201
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-3365
  • Fax: 619-543-3183
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG63547
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: