Provider Demographics
NPI:1538571864
Name:SHEREV HEART AND VASCULAR CLINIC, INC.
Entity type:Organization
Organization Name:SHEREV HEART AND VASCULAR CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIMITRI
Authorized Official - Middle Name:ATANASOV
Authorized Official - Last Name:SHEREV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-867-0557
Mailing Address - Street 1:1380 EL CAJON BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-5760
Mailing Address - Country:US
Mailing Address - Phone:619-867-0557
Mailing Address - Fax:619-867-0558
Practice Address - Street 1:1380 EL CAJON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-5760
Practice Address - Country:US
Practice Address - Phone:619-867-0557
Practice Address - Fax:619-867-0558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RC0001X
CAA70917207RI0011X, 207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9024740Medicaid
CAH59470Medicare UPIN
CA9024740Medicaid