Healthcare Provider Details

I. General information

NPI: 1740349372
Provider Name (Legal Business Name): VIDHYALAKSHMI KOKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VIDHYALAKSHMI TAYI MD

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 N SAN JACINTO ST
HEMET CA
92543-3124
US

IV. Provider business mailing address

422 N SAN JACINTO ST
HEMET CA
92543-3124
US

V. Phone/Fax

Practice location:
  • Phone: 941-665-1100
  • Fax: 888-696-2590
Mailing address:
  • Phone: 941-665-1100
  • Fax: 888-696-2590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA60821
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA60821
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA60821
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: