Provider Demographics
NPI:1659885838
Name:RAYADURG, ROOPA
Entity Type:Individual
Prefix:
First Name:ROOPA
Middle Name:
Last Name:RAYADURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 FERNDALE WAY
Mailing Address - Street 2:
Mailing Address - City:EMERALD HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:94062-3906
Mailing Address - Country:US
Mailing Address - Phone:650-274-8719
Mailing Address - Fax:
Practice Address - Street 1:242 FERNDALE WAY
Practice Address - Street 2:
Practice Address - City:EMERALD HILLS
Practice Address - State:CA
Practice Address - Zip Code:94062-3906
Practice Address - Country:US
Practice Address - Phone:650-274-8719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-26
Last Update Date:2017-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24408261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy