Healthcare Provider Details

I. General information

NPI: 1861792558
Provider Name (Legal Business Name): RAVEENDRA NADARAJA, M.D., F.A.C.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20055 LAKE CHABOT RD STE 330
CASTRO VALLEY CA
94546-5334
US

IV. Provider business mailing address

20055 LAKE CHABOT RD STE 330
CASTRO VALLEY CA
94546-5334
US

V. Phone/Fax

Practice location:
  • Phone: 510-538-2146
  • Fax: 510-538-7959
Mailing address:
  • Phone: 510-538-2146
  • Fax: 510-538-7959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GOWRI NADARAJA
Title or Position: MANAGER
Credential:
Phone: 510-538-2146