Provider Demographics
NPI:1972142719
Name:CATHEDRAL MEDICAL INC.
Entity Type:Organization
Organization Name:CATHEDRAL MEDICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIKRAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:KOTHANDARAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-840-4757
Mailing Address - Street 1:PO BOX 57629
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-0629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2226 E CESAR E CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1825
Practice Address - Country:US
Practice Address - Phone:323-266-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHEDRAL MEDICAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXXX1234Medicaid