Provider Demographics
NPI:1700250578
Name:KANAKAVALLI SURESH IYER, M.D., INC.
Entity Type:Organization
Organization Name:KANAKAVALLI SURESH IYER, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KANAKAVALLI
Authorized Official - Middle Name:
Authorized Official - Last Name:IYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-907-9561
Mailing Address - Street 1:2310 SUNNY POINT ST
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-1143
Mailing Address - Country:US
Mailing Address - Phone:805-907-9561
Mailing Address - Fax:951-272-9924
Practice Address - Street 1:1950 E LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3503
Practice Address - Country:US
Practice Address - Phone:805-907-9561
Practice Address - Fax:951-272-9924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56234207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB236552Medicare PIN