Healthcare Provider Details

I. General information

NPI: 1740340041
Provider Name (Legal Business Name): RAMA S VENKAT M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 S BREA CANYON RD STE H
DIAMOND BAR CA
91765-3481
US

IV. Provider business mailing address

636 PANTERA DR
DIAMOND BAR CA
91765-1855
US

V. Phone/Fax

Practice location:
  • Phone: 909-594-1848
  • Fax: 909-594-7959
Mailing address:
  • Phone: 909-396-9669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA044468
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: