Healthcare Provider Details

I. General information

NPI: 1720270820
Provider Name (Legal Business Name): PREM SAHASRANAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 W LACEY BLVD SUITE 201
HANFORD CA
93230-5965
US

IV. Provider business mailing address

PO BOX 1669
HANFORD CA
93232-1669
US

V. Phone/Fax

Practice location:
  • Phone: 559-410-7801
  • Fax: 559-380-2406
Mailing address:
  • Phone: 559-587-1100
  • Fax: 559-587-9044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA91333
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: