Basic Information
Provider Information | |||||||||
NPI: | 1467732297 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHASHITA INAMDAR MD PROFESSIONAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 845 LA JOLLA RANCHO RD | ||||||||
Address2: |   | ||||||||
City: | LA JOLLA | ||||||||
State: | CA | ||||||||
PostalCode: | 920377409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8584275060 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4510 EXECUTIVE DR STE 115 | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921213022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8584275060 | ||||||||
FaxNumber: | 6193836700 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2011 | ||||||||
LastUpdateDate: | 01/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | INAMDAR | ||||||||
AuthorizedOfficialFirstName: | SHASHITA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8584275060 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 01/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A102089 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.