Healthcare Provider Details

I. General information

NPI: 1558600650
Provider Name (Legal Business Name): KALYAN DANDALA, MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S 38TH CT STE 100
RENTON WA
98055-5777
US

IV. Provider business mailing address

18401 VON KARMAN AVE STE 500
IRVINE CA
92612-8531
US

V. Phone/Fax

Practice location:
  • Phone: 714-828-1800
  • Fax: 714-882-1186
Mailing address:
  • Phone: 714-828-1800
  • Fax: 714-882-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMD00048010
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP30007637
License Number StateWA

VIII. Authorized Official

Name: MAGDALEN GUSTILO
Title or Position: DIRECTOR OF PAYER RELATIONS
Credential:
Phone: 714-568-7667