Provider Demographics
NPI:1679589329
Name:WADHWA, MANISH KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:KUMAR
Last Name:WADHWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 WASHINGTON ST
Mailing Address - Street 2:SUITE 512
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2231
Mailing Address - Country:US
Mailing Address - Phone:619-297-0014
Mailing Address - Fax:619-297-1014
Practice Address - Street 1:501 WASHINGTON ST
Practice Address - Street 2:SUITE 512
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2231
Practice Address - Country:US
Practice Address - Phone:619-297-0014
Practice Address - Fax:619-297-1014
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84648207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G846480Medicaid
CARHC150029OtherX-RAY/FLUOROSCOPY
CA00G846480Medicaid
CARHC150029OtherX-RAY/FLUOROSCOPY