Healthcare Provider Details

I. General information

NPI: 1326934332
Provider Name (Legal Business Name): CENTRAL COAST GASTROENTEROLOGY ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 PARK AVE STE D
SOQUEL CA
95073-2956
US

IV. Provider business mailing address

20 PASATIEMPO DR
SANTA CRUZ CA
95060-1807
US

V. Phone/Fax

Practice location:
  • Phone: 831-260-3591
  • Fax: 800-785-5318
Mailing address:
  • Phone: 831-800-7887
  • Fax: 831-998-7155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: VIJAYA MUKTHINUTHALAPATI
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 831-800-7887