Healthcare Provider Details

I. General information

NPI: 1649589052
Provider Name (Legal Business Name): CHAMPAK VENKITACHALAM MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2010
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 29TH ST STE 480
SACRAMENTO CA
95816-5173
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 916-733-3777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA122227
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: