Provider Demographics
NPI:1568807436
Name:SIVA PRASAD MULLANGI MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SIVA PRASAD MULLANGI MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SIVA
Authorized Official - Middle Name:P
Authorized Official - Last Name:MULLANGI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-912-4353
Mailing Address - Street 1:PO BOX 898
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-0030
Mailing Address - Country:US
Mailing Address - Phone:909-912-4353
Mailing Address - Fax:909-626-8384
Practice Address - Street 1:5365 WALNUT AVE STE I
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710
Practice Address - Country:US
Practice Address - Phone:909-315-6399
Practice Address - Fax:909-315-6696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-06
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64112208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty