Provider Demographics
NPI:1619952405
Name:PANGULURI, RANGARAO (MD)
Entity Type:Individual
Prefix:
First Name:RANGARAO
Middle Name:
Last Name:PANGULURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3307
Mailing Address - Country:US
Mailing Address - Phone:626-960-3016
Mailing Address - Fax:626-960-3517
Practice Address - Street 1:4111 MAINE AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3307
Practice Address - Country:US
Practice Address - Phone:626-960-3016
Practice Address - Fax:626-960-3517
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52987207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OOA529870424OtherCAL OPTIMA
CA00A529870Medicaid
100016964OtherRR MEDICARE
CAWA52987BMedicare ID - Type Unspecified
CA00A529870Medicaid
CAWA52987CMedicare ID - Type Unspecified
CAWA52987AMedicare ID - Type Unspecified