1760545503 NPI number — VIJAY C KATUKOTA, A MEDICAL CORPORATION

Table of content: (NPI 1760545503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760545503 NPI number — VIJAY C KATUKOTA, A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIJAY C KATUKOTA, A 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:
VIJAY C. KATUKOTA,, A MEDICAL CORPORATION
Provider Other Organization Name Type Code:
5
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:
1760545503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1177 N PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91768-3028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-623-9900
Provider Business Mailing Address Fax Number:
909-623-1993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1177 N PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91768-3028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-623-9900
Provider Business Practice Location Address Fax Number:
909-623-1993
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KATUKOTA
Authorized Official First Name:
VIJAY
Authorized Official Middle Name:
CHANDRA
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
909-623-9900

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  A38343 , 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: 00A383430 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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