MEDICARE: KOUSHIK PRUDVI KASANAGOTTU MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	186556	CA

General Provider Information

NPI Number	:	1033601844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOUSHIK PRUDVI KASANAGOTTU MD

Provider Business Mailing Address
First Line	:	5379 HAMNER AVE UNIT 801
Second Line	:
City	:	EASTVALE
State	:	CA
Zip	:	91752-1042
Country	:	US
Telephone Number	:	888-854-1397
Fax Number	:

Provider Business Practice Location Address
First Line	:	5379 HAMNER AVE UNIT 801
Second Line	:
City	:	EASTVALE
State	:	CA
Zip	:	91752-1042
Country	:	US
Telephone Number	:	888-854-1397
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2018
Last Update Date	:	11/26/2025

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