Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | A45109 | CA |
N | 208000000X | Pediatrician | A45109 | CA |
NPI | 1245264902 |
---|---|
Provider Name | Mr. Marigangaiah Mahadev |
First Address | Anaheim Hills, CA 92808 |
Second Address | Anaheim Hills, CA 92808 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2006 |
Last Update Date | 13/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A451091 | (05) | CA |
F22627 | (02) |