Provider Demographics
NPI:1972641736
Name:EVERGREEN PEDIATRICS INC
Entity Type:Organization
Organization Name:EVERGREEN PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PRONOTI
Authorized Official - Middle Name:
Authorized Official - Last Name:NIGAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-238-8303
Mailing Address - Street 1:4205 SAN FELIPE RD
Mailing Address - Street 2:#110
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95135-1503
Mailing Address - Country:US
Mailing Address - Phone:408-238-8303
Mailing Address - Fax:408-238-8375
Practice Address - Street 1:4205 SAN FELIPE RD
Practice Address - Street 2:#110
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95135-1503
Practice Address - Country:US
Practice Address - Phone:408-238-8303
Practice Address - Fax:408-238-8375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33613208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C431251Medicaid
CA00A336130Medicaid
CAR09208OtherBLUE CROSS MEDICAL
CA1053390310OtherPRONOTI NIGAM MD NPI
CA1750497608OtherZAHIDA P MALIKMD NPI
R09238OtherBLUE CROSS MEDICAL