Provider Demographics
NPI:1922284975
Name:PEZESHKI, SHADI
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:PEZESHKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1208
Mailing Address - Country:US
Mailing Address - Phone:858-554-1212
Mailing Address - Fax:858-795-1195
Practice Address - Street 1:9850 GENESEE AVE STE 320
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1208
Practice Address - Country:US
Practice Address - Phone:858-554-1212
Practice Address - Fax:858-795-1195
Is Sole Proprietor?:No
Enumeration Date:2008-01-20
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDOO66815207R00000X
CAC174931207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine