Healthcare Provider Details

I. General information

NPI: 1700345709
Provider Name (Legal Business Name): SRIDEVI KESAVAN KORAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11332 MOUNTAIN VIEW AVE STE C
LOMA LINDA CA
92354-3854
US

IV. Provider business mailing address

11332 MOUNTAIN VIEW AVE STE C
LOMA LINDA CA
92354-3854
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-6131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA178658
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberA178658
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: