Healthcare Provider Details

I. General information

NPI: 1235498361
Provider Name (Legal Business Name): PRIYAM VADA TRIPATHI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MED PLAZA SUITE 420, 365, 120
LOS ANGELES CA
90045-5631
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-855-7002
  • Fax:
Mailing address:
  • Phone: 310-301-8707
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA137372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: