Healthcare Provider Details

I. General information

NPI: 1679589329
Provider Name (Legal Business Name): MANISH KUMAR WADHWA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WASHINGTON ST SUITE 512
SAN DIEGO CA
92103-2231
US

IV. Provider business mailing address

501 WASHINGTON ST SUITE 512
SAN DIEGO CA
92103-2231
US

V. Phone/Fax

Practice location:
  • Phone: 619-297-0014
  • Fax: 619-297-1014
Mailing address:
  • Phone: 619-297-0014
  • Fax: 619-297-1014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberG84648
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: