Provider Demographics
NPI:1326156431
Name:CHANNABASAVAIAH, ANITHA
Entity Type:Individual
Prefix:
First Name:ANITHA
Middle Name:
Last Name:CHANNABASAVAIAH
Suffix:
Gender:F
Credentials:
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 576368
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-6368
Mailing Address - Country:US
Mailing Address - Phone:209-485-3898
Mailing Address - Fax:
Practice Address - Street 1:4501 DALE ROAD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356
Practice Address - Country:US
Practice Address - Phone:209-485-3898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83221207R00000X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicaid
CAPENDINGMedicaid
CA00A832210Medicare ID - Type Unspecified