Healthcare Provider Details

I. General information

NPI: 1649224387
Provider Name (Legal Business Name): VACHASPATHI PALAKODETI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 WEST ATEN ROAD SUITE 1
IMPERIAL CA
92251
US

IV. Provider business mailing address

516 WEST ATEN ROAD SUITE 2
IMPERIAL CA
92251
US

V. Phone/Fax

Practice location:
  • Phone: 760-355-8300
  • Fax: 760-545-0240
Mailing address:
  • Phone: 760-355-7730
  • Fax: 760-355-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA52484
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: