Provider Demographics
NPI:1285658807
Name:IYER, KANAKAVALLI SURESH (MD)
Entity Type:Individual
Prefix:
First Name:KANAKAVALLI
Middle Name:SURESH
Last Name:IYER
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:PO BOX 7001
Mailing Address - Street 2:1000
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-7001
Mailing Address - Country:US
Mailing Address - Phone:818-888-7815
Mailing Address - Fax:818-715-1722
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:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56234207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A562340OtherBLUE SHIELD
CA00A562340Medicaid
CA00A562340OtherBLUE SHIELD
CA00A562340Medicaid