MEDICARE: DR. VRIJESH SHANTANU TANTUWAYA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician	A79530	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45688	OTHER	AZ	MEDICAL LICENSE

General Provider Information

NPI Number	:	1235134966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VRIJESH SHANTANU TANTUWAYA MD

Provider Business Mailing Address
First Line	:	12630 MONTE VISTA RD
Second Line	:	SUITE 105
City	:	POWAY
State	:	CA
Zip	:	92064-2530
Country	:	US
Telephone Number	:	858-312-5016
Fax Number	:	858-312-5018

Provider Business Practice Location Address
First Line	:	12630 MONTE VISTA RD
Second Line	:	SUITE 105
City	:	POWAY
State	:	CA
Zip	:	92064-2530
Country	:	US
Telephone Number	:	858-312-5016
Fax Number	:	858-312-5018

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	05/03/2013

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