Provider Demographics
NPI:1336211648
Name:SUDANAGUNTA, PERAIAH (MD)
Entity Type:Individual
Prefix:DR
First Name:PERAIAH
Middle Name:
Last Name:SUDANAGUNTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PERAIAH
Other - Middle Name:
Other - Last Name:SUDANAGUNTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1408
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-1408
Mailing Address - Country:US
Mailing Address - Phone:209-710-6331
Mailing Address - Fax:209-827-8224
Practice Address - Street 1:400 WEST I ST
Practice Address - Street 2:
Practice Address - City:LOS BANAS
Practice Address - State:CA
Practice Address - Zip Code:93635
Practice Address - Country:US
Practice Address - Phone:209-710-6331
Practice Address - Fax:209-827-8224
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24549208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A245490Medicaid
CAA86797Medicare UPIN
CA00A245490Medicaid