1699877480 NPI number — VENUGOPAL DEPALA MD

Table of content: VENUGOPAL DEPALA MD (NPI 1699877480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699877480 NPI number — VENUGOPAL DEPALA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEPALA
Provider First Name:
VENUGOPAL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1699877480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 892998
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMECULA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92589-2998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-737-5787
Provider Business Mailing Address Fax Number:
951-296-3585

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27349 JEFFERSON AVE
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
TEMECULA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92590-5634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-737-5787
Provider Business Practice Location Address Fax Number:
951-296-3585
Provider Enumeration Date:
09/02/2006

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: 2084P0800X , with the licence number:  C52648 , 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: 00C526480 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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