Provider Demographics
NPI:1275510711
Name:GADDAM, SYAM P (MD)
Entity Type:Individual
Prefix:
First Name:SYAM
Middle Name:P
Last Name:GADDAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11922 SEACREST DR
Mailing Address - Street 2:STE A
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-1937
Mailing Address - Country:US
Mailing Address - Phone:714-636-9100
Mailing Address - Fax:714-636-1806
Practice Address - Street 1:11922 SEACREST DR
Practice Address - Street 2:STE A
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-1937
Practice Address - Country:US
Practice Address - Phone:714-636-9100
Practice Address - Fax:714-636-1806
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA50714207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A507140Medicaid
CA100016963Medicare PIN
CAWA50714BMedicare PIN
CAWA50714AMedicare PIN
CAWA50714DMedicare PIN
CA100016966Medicare PIN
CA00A507140Medicaid