Provider Demographics
NPI:1013339084
Name:TAKESHIA C. NIDAY, M.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:TAKESHIA C. NIDAY, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAKESHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-500-6566
Mailing Address - Street 1:2760 FIFTH AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6325
Mailing Address - Country:US
Mailing Address - Phone:619-500-6566
Mailing Address - Fax:619-374-2982
Practice Address - Street 1:2760 FIFTH AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6325
Practice Address - Country:US
Practice Address - Phone:619-500-6566
Practice Address - Fax:619-374-2982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA113548261QM0801X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)