Provider Demographics
NPI:1235143306
Name:ULLAL, VIVEK RATNAKAR (MD)
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:RATNAKAR
Last Name:ULLAL
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 1:101 S 1ST ST
Mailing Address - Street 2:1000
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1938
Mailing Address - Country:US
Mailing Address - Phone:818-845-6206
Mailing Address - Fax:818-845-9774
Practice Address - Street 1:2975 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1201
Practice Address - Country:US
Practice Address - Phone:805-955-6900
Practice Address - Fax:805-955-6063
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34774207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A347741Medicaid
CA00A347740OtherBLUE SHIELD
CAA34774EMedicare ID - Type Unspecified
CACA920ZMedicare PIN
CA00A347741Medicaid