Provider Demographics
NPI:1831311984
Name:DATE, AMIT (MD, MBA)
Entity type:Individual
Prefix:
First Name:AMIT
Middle Name:
Last Name:DATE
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2674 COSTEBELLE DR
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-3516
Mailing Address - Country:US
Mailing Address - Phone:217-417-5511
Mailing Address - Fax:
Practice Address - Street 1:5405 OBERLIN DR FL 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1700
Practice Address - Country:US
Practice Address - Phone:858-909-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-049364207Y00000X
IL036126212207Y00000X
CAC177918207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2613OtherMEDICARE GROUP PTAN
ILIL2613057OtherMEDICARE INDIVIDUAL PTAN