Provider Demographics
NPI:1003928565
Name:VAIDYARAMAN, MUTHUKUMAR (MD,FIPP, MBA)
Entity Type:Individual
Prefix:DR
First Name:MUTHUKUMAR
Middle Name:
Last Name:VAIDYARAMAN
Suffix:
Gender:M
Credentials:MD,FIPP, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12040 DARBY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1112
Mailing Address - Country:US
Mailing Address - Phone:818-217-4730
Mailing Address - Fax:
Practice Address - Street 1:12040 DARBY AVE
Practice Address - Street 2:
Practice Address - City:PORTER RANCH
Practice Address - State:CA
Practice Address - Zip Code:91326-1112
Practice Address - Country:US
Practice Address - Phone:818-217-4730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90212207L00000X
CAA89024208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270695400Medicaid
FLME90212OtherMD
FL115797Medicare UPIN
FL270695400Medicaid