Healthcare Provider Details

I. General information

NPI: 1417984949
Provider Name (Legal Business Name): RENU VISHWANATH KAUSHIK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MEADOWLARK DRIVE
SAN DIEGO CA
92123
US

IV. Provider business mailing address

2901 MEADOWLARK DRIVE MSP535
SAN DIEGO CA
92123
US

V. Phone/Fax

Practice location:
  • Phone: 858-694-4752
  • Fax: 858-514-8425
Mailing address:
  • Phone: 858-694-4752
  • Fax: 858-514-8425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA67195
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number9473
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: