Provider Demographics
NPI:1669856217
Name:BANAJJAR REVANASIDDAPPA, VANITHA (MD)
Entity Type:Individual
Prefix:DR
First Name:VANITHA
Middle Name:
Last Name:BANAJJAR REVANASIDDAPPA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VANITHA
Other - Middle Name:
Other - Last Name:BANAJJAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:866-682-4842
Mailing Address - Fax:
Practice Address - Street 1:797 W CHILDS AVE
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6805
Practice Address - Country:US
Practice Address - Phone:866-682-4842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA162179207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1669856217Medicaid