Provider Demographics
NPI:1578560884
Name:KOMANAPALLI, LALITA M (MD)
Entity Type:Individual
Prefix:
First Name:LALITA
Middle Name:M
Last Name:KOMANAPALLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17360 BROOKHURST ST
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT.
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:657-241-3592
Mailing Address - Fax:
Practice Address - Street 1:18035 BROOKHURST STREET
Practice Address - Street 2:SUITE 2100
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:657-241-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64243207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A642430OtherMEDI CAL
CACB232714Medicare PIN