Healthcare Provider Details

I. General information

NPI: 1306372198
Provider Name (Legal Business Name): KD MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 06/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W I ST SUITE C
LOS BANOS CA
93635-3459
US

IV. Provider business mailing address

311 W I ST
LOS BANOS CA
93635-3479
US

V. Phone/Fax

Practice location:
  • Phone: 209-827-2766
  • Fax: 209-827-2733
Mailing address:
  • Phone: 209-826-2222
  • Fax: 209-826-0199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number5321
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5321
License Number StateCA

VIII. Authorized Official

Name: DR. KARTHIKEYA DEVIREDDY
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 209-826-2222