Healthcare Provider Details

I. General information

NPI: 1528206224
Provider Name (Legal Business Name): SOUTH BAY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JOSE FIGUERES AVE SUITE # 435
SAN JOSE CA
95116-1500
US

IV. Provider business mailing address

200 JOSE FIGUERES AVE SUITE # 435
SAN JOSE CA
95116-1500
US

V. Phone/Fax

Practice location:
  • Phone: 408-258-4244
  • Fax: 408-258-3338
Mailing address:
  • Phone: 408-258-4244
  • Fax: 408-258-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA63379
License Number StateCA

VIII. Authorized Official

Name: DR. PRASANNA L KRISHNAMSHETTY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 408-258-4244