Healthcare Provider Details

I. General information

NPI: 1487673679
Provider Name (Legal Business Name): SAMBASIVARAO VENKATA KARANAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 E. WATER ST., # B
SOUTH BEND WA
98586-1166
US

IV. Provider business mailing address

PO BOX 1166 827 E. WATER STREET # B
SOUTH BEND WA
98586-1166
US

V. Phone/Fax

Practice location:
  • Phone: 425-766-1614
  • Fax:
Mailing address:
  • Phone: 425-766-1614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD00021462
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: