Healthcare Provider Details

I. General information

NPI: 1417754433
Provider Name (Legal Business Name): MARGOSCHIS VEDAMUTHU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2025
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4941 BUNKHOUSE STREET
FREMONT CA
94555
US

IV. Provider business mailing address

4941 BUNKHOUSE ST
FREMONT CA
94555
US

V. Phone/Fax

Practice location:
  • Phone: 661-330-2772
  • Fax:
Mailing address:
  • Phone: 661-444-3991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number751125
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95034607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: