=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285773382
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH J SHERIDAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 10/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7850 VISTA HILL AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-630-1036
-----------------------------------------------------
Fax | 619-609-0059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1770
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91944-1770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-464-1165
-----------------------------------------------------
Fax | 619-567-1011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | A97596
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | A97596
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------