Healthcare Provider Details

I. General information

NPI: 1720320989
Provider Name (Legal Business Name): NANDITA PUCHAKAYALA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NANDITA KUNAM

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12555 CENTRAL AVE STE C
CHINO CA
91710-3569
US

IV. Provider business mailing address

1809 W REDLANDS BLVD
REDLANDS CA
92373-8054
US

V. Phone/Fax

Practice location:
  • Phone: 909-902-1082
  • Fax:
Mailing address:
  • Phone: 909-335-3026
  • Fax: 909-335-3167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA138716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: