=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821436684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEEPA RAGESH PANIKKATH MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2013
-----------------------------------------------------
Last Update Date | 10/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 892 AEROVISTA PL STE 210
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-8054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-549-8023
-----------------------------------------------------
Fax | 805-549-8252
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5767 W CENTURY BLVD STE 400
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90045-5631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-301-8707
-----------------------------------------------------
Fax | 310-301-8751
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | A161120
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------