Provider Demographics
NPI:1013089846
Name:PALAVALLI, JAYASUDHA S (MD)
Entity Type:Individual
Prefix:
First Name:JAYASUDHA
Middle Name:S
Last Name:PALAVALLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JAYASUDHA
Other - Middle Name:V
Other - Last Name:GODUOOR.
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3553 WHIPPLE RD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1507
Mailing Address - Country:US
Mailing Address - Phone:510-454-1000
Mailing Address - Fax:
Practice Address - Street 1:3553 WHIPPLE RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1507
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A907270Medicaid
00A907270Medicare ID - Type Unspecified
I42371Medicare UPIN