Healthcare Provider Details

I. General information

NPI: 1508783473
Provider Name (Legal Business Name): MITHILESH V TADEPALLI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39650 LIBERTY ST
FREMONT CA
94538-2223
US

IV. Provider business mailing address

PO BOX 276950
SACRAMENTO CA
95827-6950
US

V. Phone/Fax

Practice location:
  • Phone: 510-498-3900
  • Fax:
Mailing address:
  • Phone: 866-681-0738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: