Provider Demographics
NPI:1235134966
Name:TANTUWAYA, VRIJESH SHANTANU (MD)
Entity Type:Individual
Prefix:DR
First Name:VRIJESH
Middle Name:SHANTANU
Last Name:TANTUWAYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12630 MONTE VISTA RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2530
Mailing Address - Country:US
Mailing Address - Phone:858-312-5016
Mailing Address - Fax:858-312-5018
Practice Address - Street 1:12630 MONTE VISTA RD
Practice Address - Street 2:SUITE 105
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2530
Practice Address - Country:US
Practice Address - Phone:858-312-5016
Practice Address - Fax:858-312-5018
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79530207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ45688OtherMEDICAL LICENSE
AZZ156778Medicare PIN
AZ45688OtherMEDICAL LICENSE
CA5662060002Medicare NSC