Healthcare Provider Details

I. General information

NPI: 1003928565
Provider Name (Legal Business Name): MUTHUKUMAR VAIDYARAMAN MD,FIPP, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12040 DARBY AVE
PORTER RANCH CA
91326-1112
US

IV. Provider business mailing address

12040 DARBY AVE
PORTER RANCH CA
91326-1112
US

V. Phone/Fax

Practice location:
  • Phone: 818-217-4730
  • Fax:
Mailing address:
  • Phone: 818-217-4730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME90212
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA89024
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: