Provider Demographics
NPI:1710946843
Name:PADMANABHA, VENKATAPPA M (MD FACP)
Entity Type:Individual
Prefix:DR
First Name:VENKATAPPA
Middle Name:M
Last Name:PADMANABHA
Suffix:
Gender:M
Credentials:MD FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2406
Mailing Address - Country:US
Mailing Address - Phone:760-255-4700
Mailing Address - Fax:760-255-3840
Practice Address - Street 1:902 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2406
Practice Address - Country:US
Practice Address - Phone:760-255-4700
Practice Address - Fax:760-255-3840
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40810207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A408100Medicaid
CAA85511Medicare UPIN
CA00A408100Medicaid