Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | A83555 | CA |
N | 111NI0900X | Internist | A83555 | CA |
Y | 207RG0300X | Geriatric Medicine | A83555 | CA |
NPI | 1003912668 |
---|---|
Provider Name | Phanikumar Srinivasa Vadarevu |
First Address | Sacramento, CA 95825-1020 |
Second Address | Sacramento, CA 95825-1020 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/09/2006 |
Last Update Date | 14/12/2021 |