Healthcare Provider Details

I. General information

NPI: 1285634931
Provider Name (Legal Business Name): KIRAN KUMAR VALLAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N DELAWARE ST
KENNEWICK WA
99336-7750
US

IV. Provider business mailing address

317 N DELAWARE ST
KENNEWICK WA
99336-7750
US

V. Phone/Fax

Practice location:
  • Phone: 509-736-5550
  • Fax: 509-737-8281
Mailing address:
  • Phone: 509-736-5550
  • Fax: 509-737-8281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberFE00045283
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: