Healthcare Provider Details

I. General information

NPI: 1861425589
Provider Name (Legal Business Name): GEORGE VATAKENCHERRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 N EDGEMONT ST KAISER PERMANENTE
LOS ANGELES CA
90027-5209
US

IV. Provider business mailing address

10980 WELLWORTH AVE APT 212
LOS ANGELES CA
90024-6256
US

V. Phone/Fax

Practice location:
  • Phone: 323-783-7668
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA83475
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA83475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: