Provider Demographics
NPI:1568518827
Name:REGHUNATHAN, SUDHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHA
Middle Name:
Last Name:REGHUNATHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUDHA
Other - Middle Name:REGHU
Other - Last Name:NATHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3687 LAS POSAS RD
Mailing Address - Street 2:SUITE- H-187
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-1482
Mailing Address - Country:US
Mailing Address - Phone:805-445-4189
Mailing Address - Fax:805-445-9219
Practice Address - Street 1:3687 LAS POSAS RD
Practice Address - Street 2:SUITE- H-187
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-1482
Practice Address - Country:US
Practice Address - Phone:805-445-4189
Practice Address - Fax:805-445-9219
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53595207R00000X
CAA053595208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14294Medicare ID - Type UnspecifiedGROUP NUMBER
CAWA53595AMedicare ID - Type UnspecifiedINDIVIDUAL ID #
CAG68190Medicare UPIN