Provider Demographics
NPI:1629691209
Name:ANTELOPE VALLEY NEONATOLOGY GROUP
Entity Type:Organization
Organization Name:ANTELOPE VALLEY NEONATOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MURUGESAMUDALIAR
Authorized Official - Middle Name:
Authorized Official - Last Name:THANGAVEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-400-6577
Mailing Address - Street 1:220 STANDIFORD AVE STE F
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:44155 15TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4079
Practice Address - Country:US
Practice Address - Phone:661-949-5366
Practice Address - Fax:661-949-5039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA117369OtherMEDICAL BOARD CALIFORNIA
CAA34117OtherMEDICAL BOARD CALIFORNIA
CAA134941OtherMEDICAL BOARD CALIFORNIA