MEDICARE: DR. MUKUND GNANADESIKAN M.D.

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	2084P0804X	Child & Adolescent Psychiatry Physician	28084	AZ
2	2084P0804X	Child & Adolescent Psychiatry Physician	C53063	CA

General Provider Information

NPI Number	:	1699868133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MUKUND GNANADESIKAN M.D.

Provider Business Mailing Address
First Line	:	2751 NAPA VALLEY CORPORATE DR.
Second Line	:	BLDGS A & B
City	:	NAPA
State	:	CA
Zip	:	94559-6216
Country	:	US
Telephone Number	:	707-259-8167
Fax Number	:	707-259-8651

Provider Business Practice Location Address
First Line	:	2261 ELM ST
Second Line	:
City	:	NAPA
State	:	CA
Zip	:	94559-3721
Country	:	US
Telephone Number	:	707-259-8167
Fax Number	:	707-259-8651

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	08/18/2016

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