Basic Information
| Provider Information | |||||||||
| NPI: | 1902465792 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC HEART & VASCULAR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1234 W. CHAPMAN AVE | ||||||||
| Address2: | STE #101 | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928682862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145326713 | ||||||||
| FaxNumber: | 7145321169 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 W. CHAPMAN AVE | ||||||||
| Address2: | STE #101 | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928682862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145326713 | ||||||||
| FaxNumber: | 7145321169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2019 | ||||||||
| LastUpdateDate: | 06/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRISHNAN | ||||||||
| AuthorizedOfficialFirstName: | SENDHIL | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8133688814 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.