Provider Demographics
NPI:1225275233
Name:PUTHILLATH, AJITHKUMAR A (MD)
Entity Type:Individual
Prefix:DR
First Name:AJITHKUMAR
Middle Name:A
Last Name:PUTHILLATH
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 1:2626 N CALIFORNIA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5500
Mailing Address - Country:US
Mailing Address - Phone:209-466-2626
Mailing Address - Fax:209-466-2199
Practice Address - Street 1:2626 N CALIFORNIA ST
Practice Address - Street 2:SUITE B
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5500
Practice Address - Country:US
Practice Address - Phone:209-466-2626
Practice Address - Fax:206-466-2199
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA107213174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6792110001Medicare NSC