Healthcare Provider Details

I. General information

NPI: 1023256153
Provider Name (Legal Business Name): VIJAYA K. TANGELLA MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W OLIVE AVE SUITE 104
MERCED CA
95348-2436
US

IV. Provider business mailing address

750 W OLIVE AVE SUITE 104
MERCED CA
95348-2436
US

V. Phone/Fax

Practice location:
  • Phone: 209-384-2704
  • Fax:
Mailing address:
  • Phone: 209-384-2704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA045065
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA045065
License Number StateCA

VIII. Authorized Official

Name: VIJAYA K TANGELLA
Title or Position: OWNER
Credential: M.D.
Phone: 209-384-2704