Provider Demographics
NPI:1447202460
Name:HATTI, VIKRAM MYSORE (MD)
Entity Type:Individual
Prefix:DR
First Name:VIKRAM
Middle Name:MYSORE
Last Name:HATTI
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:PO BOX 10662
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92838-6662
Mailing Address - Country:US
Mailing Address - Phone:610-804-9517
Mailing Address - Fax:
Practice Address - Street 1:3902 EL CAJON BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1016
Practice Address - Country:US
Practice Address - Phone:800-922-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA927122085R0202X
PAMD4272192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB234400OtherMEDICARE PTAN
PA108140Medicare PIN
OHHA4222961Medicare PIN
OHHA4222962OtherMEDICARE PTAN
PA1016424210011Medicaid