=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932211950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUMITHRA KOMMAREDDY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 W BEVERLY BLVD C/O NICU
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-725-4331
-----------------------------------------------------
Fax | 323-889-2483
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1128 ROSE AVE
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-1878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-398-7770
-----------------------------------------------------
Fax | 626-296-2956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080N0001X
-----------------------------------------------------
Taxonomy Name | Neonatal-Perinatal Medicine Physician
-----------------------------------------------------
License Number | A43689
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------