Provider Demographics
NPI:1790711661
Name:VASANT, KISHORE K I (MD)
Entity Type:Individual
Prefix:DR
First Name:KISHORE
Middle Name:K
Last Name:VASANT
Suffix:I
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 1:25102 JEFFERSON AVE
Mailing Address - Street 2:SUITE # C
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-1707
Mailing Address - Country:US
Mailing Address - Phone:951-698-8876
Mailing Address - Fax:951-698-5560
Practice Address - Street 1:25102 JEFFERSON AVE
Practice Address - Street 2:SUITE # C
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-1707
Practice Address - Country:US
Practice Address - Phone:951-698-8876
Practice Address - Fax:951-698-5560
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33638207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A336382Medicaid
CA00A336380Medicare ID - Type Unspecified
CA00A336382Medicaid