Provider Demographics
NPI:1245264902
Name:MAHADEV, MARIGANGAIAH (MD)
Entity type:Individual
Prefix:MR
First Name:MARIGANGAIAH
Middle Name:
Last Name:MAHADEV
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 1:125 CHAPARRAL COURT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ANAHEIM HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92808
Mailing Address - Country:US
Mailing Address - Phone:714-998-1941
Mailing Address - Fax:714-998-3472
Practice Address - Street 1:125 CHAPARRAL COURT
Practice Address - Street 2:SUITE 102
Practice Address - City:ANAHEIM HILLS
Practice Address - State:CA
Practice Address - Zip Code:92808
Practice Address - Country:US
Practice Address - Phone:714-998-1941
Practice Address - Fax:714-998-3472
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45109208000000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A451091Medicaid
CA00A451091Medicaid
W19772Medicare ID - Type Unspecified