Healthcare Provider Details

I. General information

NPI: 1487097218
Provider Name (Legal Business Name): JAYALAKSHMAMMA BANGARU M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SOUTH CAROL PINE LANE
ARCADIA CA
91007
US

IV. Provider business mailing address

15 SOUTH CAROL PINE LANE
ARCADIA CA
91007
US

V. Phone/Fax

Practice location:
  • Phone: 626-234-6394
  • Fax:
Mailing address:
  • Phone: 626-234-6394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAFE32365
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: