Provider Demographics
NPI:1336198878
Name:DE, AJANTA (MD)
Entity Type:Individual
Prefix:DR
First Name:AJANTA
Middle Name:
Last Name:DE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 EL CAMINO REAL STE 200
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3102
Mailing Address - Country:US
Mailing Address - Phone:650-697-2431
Mailing Address - Fax:650-697-3659
Practice Address - Street 1:1850 EL CAMINO REAL STE 200
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3102
Practice Address - Country:US
Practice Address - Phone:650-697-2431
Practice Address - Fax:650-697-3659
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55862207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
BD7459109OtherDEA
IL31602469OtherBLUE CROSS BLUE SHIELD GROUP PROVIDER NUMBER
ILCC1592OtherRAILROAD MEDICARE GROUP PTAN NUMBER
IL209712OtherMEDICARE GROUP NUMBER
BD7459109OtherDEA
IL1164530713OtherGROUP NPI FOR CONSULTANTS IN CARDIOVASCULAR MEDICINE, S.C.
IL336-065783OtherCONTROLLED SUBSTANCE
IL961280OtherMEDICARE GROUP NUMBER FOR CONSULTANTS IN CARDIOVASCULAR MEDICINE, S.C.
ILK45404OtherMEDICARE INDIVIDUAL PTAN NUMBER
BD7459109OtherDEA