Healthcare Provider Details

I. General information

NPI: 1629265715
Provider Name (Legal Business Name): VENKAT REDDY VANGALA M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18002 HIGHWAY 18
APPLE VALLEY CA
92307
US

IV. Provider business mailing address

18002 HIGHWAY 18
APPLE VALLEY CA
92307
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-5505
  • Fax: 760-242-3502
Mailing address:
  • Phone: 760-242-5505
  • Fax: 760-242-3502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number051183
License Number StateCA

VIII. Authorized Official

Name: NRIUPAMA R VANGALA
Title or Position: ADMIN
Credential:
Phone: 760-242-5505