Provider Demographics
NPI:1245243146
Name:KHANCHUSTAMBHAM, PADMA (MD)
Entity Type:Individual
Prefix:DR
First Name:PADMA
Middle Name:
Last Name:KHANCHUSTAMBHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36101 BOB HOPE DR
Mailing Address - Street 2:STE. E-5 #117
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-2001
Mailing Address - Country:US
Mailing Address - Phone:760-464-2166
Mailing Address - Fax:760-699-7750
Practice Address - Street 1:35400 BOB HOPE DR
Practice Address - Street 2:SUITE # 209
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1772
Practice Address - Country:US
Practice Address - Phone:760-699-7117
Practice Address - Fax:760-699-7750
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86478207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA86478OtherSTATE LICENSE ID
CAAV500ZOtherMEDICARE PTAN
CAAV500ZOtherMEDICARE PTAN
CAA86478OtherSTATE LICENSE ID
CA00A864780Medicare PIN