Healthcare Provider Details

I. General information

NPI: 1912103318
Provider Name (Legal Business Name): RAGINI GUMMADAPU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12708 CORLEY DR
LAMIRADA CA
90638-1925
US

IV. Provider business mailing address

12708 CORLEY DR
LAMIRADA CA
90638-1925
US

V. Phone/Fax

Practice location:
  • Phone: 562-777-2575
  • Fax: 562-777-2575
Mailing address:
  • Phone: 562-777-2575
  • Fax: 562-777-2575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA97735
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: