Healthcare Provider Details

I. General information

NPI: 1306044540
Provider Name (Legal Business Name): JANARDHANA R KOLAVALA A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18523 CORWIN RD SUITE E
APPLE VALLEY CA
92307-2338
US

IV. Provider business mailing address

18523 CORWIN RD SUITE E
APPLE VALLEY CA
92307-2338
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-3634
  • Fax:
Mailing address:
  • Phone: 760-242-3634
  • Fax: 760-242-2119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: SHARON HALL
Title or Position: OFFICE MANAGER
Credential:
Phone: 760-242-3634