Provider Demographics
NPI:1003912668
Name:VADAREVU, PHANIKUMAR SRINIVASA (MD)
Entity Type:Individual
Prefix:
First Name:PHANIKUMAR
Middle Name:SRINIVASA
Last Name:VADAREVU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 BELL ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1020
Mailing Address - Country:US
Mailing Address - Phone:916-973-5000
Mailing Address - Fax:
Practice Address - Street 1:1825 BELL ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-1020
Practice Address - Country:US
Practice Address - Phone:916-973-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83555207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A835550Medicaid
CA000810611024OtherPHCS
CA1855781OtherGREAT WEST
CA00A835551Medicare ID - Type Unspecified
CA2240116OtherFIRST HEALTH
CA90143489OtherPACIFICARE
CA2464608OtherUNITED HEALTHCARE
CA00A835550OtherBLUE SHIELD
CA106123OtherHEALTH NET
CAA83555OtherBLUE CROSS
CA6172443OtherCIGNA
CAMCMG345900OtherWESTERN HEALTH ADVANTAGE
CA236627OtherINTERPLAN
CA7885572OtherAETNA
I01147Medicare UPIN