Healthcare Provider Details

I. General information

NPI: 1316999550
Provider Name (Legal Business Name): MADHAVI MUMMANENI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 W LA VETA AVE STE 101
ORANGE CA
92868-3928
US

IV. Provider business mailing address

805 W LA VETA AVE STE 101
ORANGE CA
92868-3928
US

V. Phone/Fax

Practice location:
  • Phone: 714-628-3136
  • Fax:
Mailing address:
  • Phone: 714-835-1800
  • Fax: 714-835-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA52454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: