Provider Demographics
NPI:1275892754
Name:SAMPATH, SRIVIDYA NARASIMHAN (MD)
Entity Type:Individual
Prefix:
First Name:SRIVIDYA
Middle Name:NARASIMHAN
Last Name:SAMPATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SRIVIDYA
Other - Middle Name:
Other - Last Name:NARASIMHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4725 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4715
Practice Address - Country:US
Practice Address - Phone:619-515-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA132576208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics