Provider Demographics
NPI:1508874298
Name:TANTISIRA, LALITA KHAODHIAR (MD)
Entity Type:Individual
Prefix:DR
First Name:LALITA
Middle Name:KHAODHIAR
Last Name:TANTISIRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LALITA
Other - Middle Name:
Other - Last Name:KHAODHIAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:800-926-8273
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC170095207RE0101X
MA152188207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110073937AMedicaid
MAA40372Medicare PIN
MAVX1750Medicare PIN