Provider Demographics
NPI:1558313916
Name:HATA, TISSA R (MD)
Entity Type:Individual
Prefix:DR
First Name:TISSA
Middle Name:R
Last Name:HATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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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:
Mailing Address - Fax:
Practice Address - Street 1:200 WEST ARBOR DRIVE MC 8201
Practice Address - Street 2:UCSD MEDICAL CENTER
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-8201
Practice Address - Country:US
Practice Address - Phone:619-543-3365
Practice Address - Fax:619-543-3183
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG63547207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G635470Medicaid
CA00G635470Medicaid
CAF78883Medicare UPIN