Provider Demographics
NPI:1649224387
Name:PALAKODETI, VACHASPATHI (MD)
Entity Type:Individual
Prefix:MR
First Name:VACHASPATHI
Middle Name:
Last Name:PALAKODETI
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 1:516 WEST ATEN ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:516 WEST ATEN ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251
Practice Address - Country:US
Practice Address - Phone:760-355-8300
Practice Address - Fax:760-545-0240
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52484207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066313OtherMEDI CAL GROUP NUMBER
CA00A524840Medicaid
CAWA52484JOtherMEDICARE PTAN
CAZZZ54781ZOtherBLUE SHIELD OF CALIFORNIA
CAGR0066313OtherMEDI CAL GROUP NUMBER
CAWA52484JOtherMEDICARE PTAN
G50338Medicare UPIN
CA00A524840Medicaid
CAW13536GMedicare PIN
CA110153593Medicare PIN