1568807436 NPI number — SIVA PRASAD MULLANGI MD A PROFESSIONAL MEDICAL CORPORATION

Table of content: (NPI 1568807436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568807436 NPI number — SIVA PRASAD MULLANGI MD A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIVA PRASAD MULLANGI MD A PROFESSIONAL MEDICAL CORPORATION
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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1568807436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 898
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHINO HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91709-0030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-912-4353
Provider Business Mailing Address Fax Number:
909-626-8384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5365 WALNUT AVE STE I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-315-6399
Provider Business Practice Location Address Fax Number:
909-315-6696
Provider Enumeration Date:
05/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MULLANGI
Authorized Official First Name:
SIVA
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-912-4353

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  A64112 , 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)





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