Provider Demographics
NPI:1730470022
Name:ANITHA CHANNABASAVAIAH, MD INC.
Entity Type:Organization
Organization Name:ANITHA CHANNABASAVAIAH, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANNABASAVAIAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-458-3898
Mailing Address - Street 1:PO BOX 576368
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-6368
Mailing Address - Country:US
Mailing Address - Phone:209-458-3898
Mailing Address - Fax:209-551-5720
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4404
Practice Address - Country:US
Practice Address - Phone:209-458-3898
Practice Address - Fax:209-551-5720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83221207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty