Healthcare Provider Details

I. General information

NPI: 1225566102
Provider Name (Legal Business Name): SHREESH KESHAVA PRASAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11515 EL CAMINO REAL STE 100
SAN DIEGO CA
92130-3034
US

IV. Provider business mailing address

11515 EL CAMINO REAL STE 100
SAN DIEGO CA
92130-3034
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax:
Mailing address:
  • Phone: 858-279-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA158631
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA158631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: