Provider Demographics
NPI:1790830511
Name:AMATYA, SUDHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHA
Middle Name:
Last Name:AMATYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUDHA
Other - Middle Name:SHRESTHA
Other - Last Name:AMATYA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-906-4564
Practice Address - Street 1:5454 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3621
Practice Address - Country:US
Practice Address - Phone:619-515-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350877842080A0000X
CAA51563208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2657987Medicaid