Healthcare Provider Details

I. General information

NPI: 1285297747
Provider Name (Legal Business Name): C S DUSHYANT MUKKAMALA VENKATA MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W 5TH ST
HANFORD CA
93230-5029
US

IV. Provider business mailing address

305 E CENTER AVE
VISALIA CA
93291-6331
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 559-737-4775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number71875
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number186873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: