Healthcare Provider Details

I. General information

NPI: 1962030726
Provider Name (Legal Business Name): GEORGE JOSEPH KAVALAM MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 CIRCADIAN WAY STE A
SANTA ROSA CA
95407-5457
US

IV. Provider business mailing address

2301 CIRCADIAN WAY STE A
SANTA ROSA CA
95407-5457
US

V. Phone/Fax

Practice location:
  • Phone: 707-526-2027
  • Fax:
Mailing address:
  • Phone: 707-526-2027
  • Fax: 707-526-2096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number285889
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA201849
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: