Provider Demographics
NPI:1508124918
Name:CHAVAKULA, VAMSIDHAR (MD)
Entity Type:Individual
Prefix:
First Name:VAMSIDHAR
Middle Name:
Last Name:CHAVAKULA
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 1:3750 CONVOY ST STE 301
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3741
Mailing Address - Country:US
Mailing Address - Phone:619-297-4481
Mailing Address - Fax:
Practice Address - Street 1:3750 CONVOY ST STE 301
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3741
Practice Address - Country:US
Practice Address - Phone:619-297-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA271481207T00000X
CAA169139207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery