Provider Demographics
NPI:1043228083
Name:VADMAL, MANJUNATH S (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJUNATH
Middle Name:S
Last Name:VADMAL
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 1:8950 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 171
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3561
Mailing Address - Country:US
Mailing Address - Phone:323-935-8800
Mailing Address - Fax:323-935-8804
Practice Address - Street 1:2720 W MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-3034
Practice Address - Country:US
Practice Address - Phone:818-842-8000
Practice Address - Fax:323-935-8804
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73000207ZP0102X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A730000Medicaid
CA220031112OtherRAILROAD MEDICARE
CA00A730000OtherBLUE SHIELD
CAWA73000AMedicare PIN
CAWA73000BMedicare PIN
CA00A730000OtherBLUE SHIELD