Provider Demographics
NPI:1689841686
Name:LAXMISAN, ARCHANA (MD MA)
Entity type:Individual
Prefix:DR
First Name:ARCHANA
Middle Name:
Last Name:LAXMISAN
Suffix:
Gender:F
Credentials:MD MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 GENESEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4219
Mailing Address - Country:US
Mailing Address - Phone:858-616-2872
Mailing Address - Fax:858-616-8758
Practice Address - Street 1:2020 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4219
Practice Address - Country:US
Practice Address - Phone:858-616-2872
Practice Address - Fax:858-616-8758
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37823207R00000X
TXN7302207R00000X
390200000X
CAC56078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX316822101Medicaid
IAI0923075Medicare PIN
IAP00617068Medicare PIN
TX275667YKQHMedicare PIN