Provider Demographics
NPI:1396041042
Name:NAMBISAN, MAYA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYA
Middle Name:
Last Name:NAMBISAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-1090
Mailing Address - Country:US
Mailing Address - Phone:209-334-1800
Mailing Address - Fax:209-334-2416
Practice Address - Street 1:1191 E YOSEMITE AVE STE C
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-5071
Practice Address - Country:US
Practice Address - Phone:209-824-2202
Practice Address - Fax:209-824-2205
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111198174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist