Provider Demographics
NPI:1053500991
Name:GREATER VALLEY PHYSICIANS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:GREATER VALLEY PHYSICIANS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKSHMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKANDURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-961-2461
Mailing Address - Street 1:2219 S HACIENDA BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-4639
Mailing Address - Country:US
Mailing Address - Phone:626-961-2461
Mailing Address - Fax:626-330-5392
Practice Address - Street 1:2219 S HACIENDA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-4639
Practice Address - Country:US
Practice Address - Phone:626-961-2461
Practice Address - Fax:626-330-5392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49715261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A49715Medicaid
CAF32536Medicare UPIN