MEDICARE: GEORGE VATAKENCHERRY 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	2085R0202X	Diagnostic Radiology Physician	A83475	CA
2	2085R0204X	Vascular & Interventional Radiology Physician	A83475	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00A834750	OTHER	CA	MEDICAL

General Provider Information

NPI Number	:	1861425589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE VATAKENCHERRY MD

Provider Business Mailing Address
First Line	:	10980 WELLWORTH AVE
Second Line	:	APT 212
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-6256
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1505 N EDGEMONT ST
Second Line	:	KAISER PERMANENTE
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-5209
Country	:	US
Telephone Number	:	323-783-7668
Fax Number	:

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

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	11/29/2021

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