Provider Demographics
NPI:1558600650
Name:KALYAN DANDALA, MD PLLC
Entity Type:Organization
Organization Name:KALYAN DANDALA, MD PLLC
Other - Org Name:DANMED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MAGDALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTILO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-568-7667
Mailing Address - Street 1:18401 VON KARMAN AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-8531
Mailing Address - Country:US
Mailing Address - Phone:714-828-1800
Mailing Address - Fax:714-882-1186
Practice Address - Street 1:350 S 38TH CT STE 100
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5777
Practice Address - Country:US
Practice Address - Phone:714-828-1800
Practice Address - Fax:714-882-1186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000480102084P0802X
WAAP30007637363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty