1578614657 NPI number — DR. LAKSHMAN D MAKANDURA M.D

Table of content: DR. LAKSHMAN D MAKANDURA M.D (NPI 1578614657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578614657 NPI number — DR. LAKSHMAN D MAKANDURA M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAKANDURA
Provider First Name:
LAKSHMAN
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

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:
1578614657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 S SUNSET AVE
Provider Second Line Business Mailing Address:
SUITE # 8
Provider Business Mailing Address City Name:
WEST COVINA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91790-3409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-338-8407
Provider Business Mailing Address Fax Number:
626-338-3937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 S SUNSET AVE
Provider Second Line Business Practice Location Address:
SUITE # 8
Provider Business Practice Location Address City Name:
WEST COVINA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91790-3409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-338-8407
Provider Business Practice Location Address Fax Number:
626-338-3937
Provider Enumeration Date:
01/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  A049715 , 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: 00A497153 . This is a "MEDI CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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