Provider Demographics
NPI:1457324808
Name:KOMMINENI, BHUPAL (MD FACP)
Entity Type:Individual
Prefix:
First Name:BHUPAL
Middle Name:
Last Name:KOMMINENI
Suffix:
Gender:M
Credentials:MD FACP
Other - Prefix:
Other - First Name:BHUPAL
Other - Middle Name:JC BOSE
Other - Last Name:KOMMINENI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1330 SAN BERNARDINO ROAD
Mailing Address - Street 2:SUITE G
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4974
Mailing Address - Country:US
Mailing Address - Phone:909-981-0989
Mailing Address - Fax:909-949-6214
Practice Address - Street 1:1330 SAN BERNARDINO ROAD
Practice Address - Street 2:SUITE G
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4974
Practice Address - Country:US
Practice Address - Phone:909-981-0989
Practice Address - Fax:909-949-6214
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A346510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A346510Medicaid
CA953729807OtherTAX ID
CA00A346510Medicare ID - Type Unspecified
CA953729807OtherTAX ID