Provider Demographics
NPI:1558302943
Name:SAMUDRALA, SRINATH (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINATH
Middle Name:
Last Name:SAMUDRALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1488
Practice Address - Street 1:160 E ARTESIA ST STE 220
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2921
Practice Address - Country:US
Practice Address - Phone:909-865-1020
Practice Address - Fax:909-865-1202
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2018-09-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG83088207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G830880Medicaid
CAWG83088CMedicare PIN
CA00G830880Medicaid