Provider Demographics
NPI:1114959475
Name:PATHAK, MAYANK SHAMI (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYANK
Middle Name:SHAMI
Last Name:PATHAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1140 W LA VETA AVE
Mailing Address - Street 2:SUITE 730
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4223
Mailing Address - Country:US
Mailing Address - Phone:714-541-6800
Mailing Address - Fax:714-541-1119
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:SUITE 730
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4223
Practice Address - Country:US
Practice Address - Phone:714-541-6800
Practice Address - Fax:714-541-1119
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0768332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG42568Medicare UPIN