1366983892 NPI number — SYAM P VUNNAMADALA MEDICAL CORP

Table of content: (NPI 1366983892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366983892 NPI number — SYAM P VUNNAMADALA MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYAM P VUNNAMADALA MEDICAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366983892
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 VIA GIADA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT COAST
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92657-1623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1211 W LA PALMA AVE STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANAHEIM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92801-2815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-491-3928
Provider Business Practice Location Address Fax Number:
714-491-3960
Provider Enumeration Date:
03/16/2017

Additional Information

Authorized Official

Authorized Official Last Name:
VUNNAMADALA
Authorized Official First Name:
SYAM
Authorized Official Middle Name:
P
Authorized Official Title or Position:
SOLE OWNER
Authorized Official Telephone Number:
714-491-3928

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A64189 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A641890 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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