Provider Demographics
NPI:1528206224
Name:SOUTH BAY PEDIATRICS
Entity Type:Organization
Organization Name:SOUTH BAY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KRISHNAMSHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-258-4244
Mailing Address - Street 1:200 JOSE FIGUERES AVE
Mailing Address - Street 2:SUITE # 435
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1500
Mailing Address - Country:US
Mailing Address - Phone:408-258-4244
Mailing Address - Fax:408-258-3338
Practice Address - Street 1:200 JOSE FIGUERES AVE
Practice Address - Street 2:SUITE # 435
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1500
Practice Address - Country:US
Practice Address - Phone:408-258-4244
Practice Address - Fax:408-258-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63379261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care