Provider Demographics
NPI:1972740157
Name:RAMAIAH, PURUSHOTHAM (MD)
Entity Type:Individual
Prefix:
First Name:PURUSHOTHAM
Middle Name:
Last Name:RAMAIAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PURUSHOTHAMA
Other - Middle Name:GOWDA
Other - Last Name:MADIHALLIRAMAIAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11201 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92357-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11201 BENTON ST
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-1000
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109035207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACN900ZMedicare PIN