Provider Demographics
NPI:1265525174
Name:GURUDEVAN, SWAMINATHA V (MD)
Entity type:Individual
Prefix:
First Name:SWAMINATHA
Middle Name:V
Last Name:GURUDEVAN
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 1:16229 DORILEE LN
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4201
Mailing Address - Country:US
Mailing Address - Phone:619-733-9131
Mailing Address - Fax:818-545-7606
Practice Address - Street 1:1111 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1716
Practice Address - Country:US
Practice Address - Phone:212-523-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70212207R00000X, 207RC0000X
NY317145207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A702120Medicaid
CAA70212OtherCA MEDICAL BOARD
CAA70212OtherCA MEDICAL BOARD
CA00A702120Medicaid
CAI30405Medicare UPIN