Provider Demographics
NPI:1942649561
Name:MUDAMBI, KIRAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRAN
Middle Name:
Last Name:MUDAMBI
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 1:1586 RESPONSE ROAD, APT 2087
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815
Mailing Address - Country:US
Mailing Address - Phone:650-267-0562
Mailing Address - Fax:
Practice Address - Street 1:2516 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2208
Practice Address - Country:US
Practice Address - Phone:650-267-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD609131362080P0206X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program