Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0214X | Pediatric Pulmonologist | A49339 | CA |
NPI | 1003969429 |
---|---|
Provider Name | Dr. Sudhakar Reddivalam |
First Address | Madera, CA 93638-8761 |
Second Address | Madera, CA 93638-8761 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A493390 | INDIVIDUAL NUMBER (01) | CA |
F28687 | (02) | CA |
GR0103350 | (05) | CA |