MEDICARE: LOGESH SWAYAMPRAKASAM

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	1223P0300X	Periodontics	30-023111	OH
2	1223P0300X	Periodontics	100140	CA

General Provider Information

NPI Number	:	1215262225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGESH SWAYAMPRAKASAM

Provider Business Mailing Address
First Line	:	4688 MOWRY AVE
Second Line	:
City	:	FREMONT
State	:	CA
Zip	:	94538-1148
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1761 E CAPITOL EXPY
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95121-1561
Country	:	US
Telephone Number	:	408-484-3891
Fax Number	:

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

Provider Enumeration Date	:	10/08/2009
Last Update Date	:	09/30/2022

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Directions to “ LOGESH SWAYAMPRAKASAM ” Practice Location

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