Healthcare Provider Details

I. General information

NPI: 1093129801
Provider Name (Legal Business Name): KETNA MISTRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DNA WAY MS 8214
SOUTH SAN FRANCISCO CA
94080-4918
US

IV. Provider business mailing address

1 DNA WAY MS 8214
SOUTH SAN FRANCISCO CA
94080-4918
US

V. Phone/Fax

Practice location:
  • Phone: 650-303-6097
  • Fax:
Mailing address:
  • Phone: 650-303-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46699
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: