Provider Demographics
NPI:1013004571
Name:VEST, ISHAN BALTHAZAR (DC)
Entity Type:Individual
Prefix:
First Name:ISHAN
Middle Name:BALTHAZAR
Last Name:VEST
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 WASHINGTON ST
Mailing Address - Street 2:# 101
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-1908
Mailing Address - Country:US
Mailing Address - Phone:650-994-4455
Mailing Address - Fax:650-994-7534
Practice Address - Street 1:550 WASHINGTON ST
Practice Address - Street 2:# 101
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-1908
Practice Address - Country:US
Practice Address - Phone:650-994-4455
Practice Address - Fax:650-994-7534
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18679111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0186790OtherBLUE SHIELD
CADC0186790Medicare UPIN