Provider Demographics
NPI:1376558239
Name:KUNAMNEMI, BASAVA (MD)
Entity Type:Individual
Prefix:
First Name:BASAVA
Middle Name:
Last Name:KUNAMNEMI
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 1:2800 N CALIFORNIA STREET
Mailing Address - Street 2:SUITE 14
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204
Mailing Address - Country:US
Mailing Address - Phone:209-942-1005
Mailing Address - Fax:209-942-0455
Practice Address - Street 1:2800 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-464-7681
Practice Address - Fax:209-464-1647
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00C51232D207R00000X
CA00C512320207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00473872OtherRAILROAD MEDICARE
CA00C51232DMedicaid
00C51232DMedicare ID - Type Unspecified
CA00C51232DMedicaid