Provider Demographics
NPI:1306044540
Name:JANARDHANA R KOLAVALA A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JANARDHANA R KOLAVALA A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-242-3634
Mailing Address - Street 1:18523 CORWIN RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2338
Mailing Address - Country:US
Mailing Address - Phone:760-242-3634
Mailing Address - Fax:760-242-2119
Practice Address - Street 1:18523 CORWIN RD
Practice Address - Street 2:SUITE E
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2338
Practice Address - Country:US
Practice Address - Phone:760-242-3634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA290000417OtherRAILROAD MEDICARE
CA00A38782Medicaid
CA290000417OtherRAILROAD MEDICARE
CA00A387820Medicare PIN