Healthcare Provider Details

I. General information

NPI: 1497840888
Provider Name (Legal Business Name): PURNIMA G KUDLU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 TREAT BLVD SUITE 140
WALNUT CREEK CA
94597-2168
US

IV. Provider business mailing address

DEPT 34929 P.O. BOX 39000
SAN FRANCISCO CA
94139-0001
US

V. Phone/Fax

Practice location:
  • Phone: 925-296-9784
  • Fax: 925-296-9092
Mailing address:
  • Phone: 925-952-2828
  • Fax: 925-952-2850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA78232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: