Healthcare Provider Details

I. General information

NPI: 1750602223
Provider Name (Legal Business Name): SANTHOSH MUKUND NADIPURAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD STE 4221
WEST HOLLYWOOD CA
90048
US

IV. Provider business mailing address

8700 BEVERLY BLVD STE 4221
WEST HOLLYWOOD CA
90048-1804
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-4471
  • Fax:
Mailing address:
  • Phone: 310-423-4471
  • Fax: 310-434-8284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA112411
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberA112411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: