Provider Demographics
NPI:1912034141
Name:KAMBAM, PRAVEEN REDDY (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:REDDY
Last Name:KAMBAM
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 1:644 N FULLER AVE PMB 7190
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-1939
Mailing Address - Country:US
Mailing Address - Phone:310-231-8964
Mailing Address - Fax:310-627-1657
Practice Address - Street 1:11500 W OLYMPIC BLVD
Practice Address - Street 2:538
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064
Practice Address - Country:US
Practice Address - Phone:310-231-8964
Practice Address - Fax:310-627-1657
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1004572084P0800X, 2084A0401X, 2084F0202X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry