1639100662 NPI number — SOUTHERN CALIFORNIA INFECTIOUS DISEASE MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639100662 NPI number — SOUTHERN CALIFORNIA INFECTIOUS DISEASE MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN CALIFORNIA INFECTIOUS DISEASE MEDICAL GROUP
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:
1639100662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA HABRA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90632-2190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-483-0901
Provider Business Mailing Address Fax Number:
213-483-6650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 TOWNSGATE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WESTLAKE VILLAGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91361-5986
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-483-0901
Provider Business Practice Location Address Fax Number:
213-483-6650
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RADHAKRISHNA
Authorized Official First Name:
SUMAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MD/PARTNER
Authorized Official Telephone Number:
213-483-0901

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  W11997 , 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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