Provider Demographics
NPI:1740867407
Name:KOSARAJU, PRIYANKA SHARMA
Entity type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:SHARMA
Last Name:KOSARAJU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13160 MINDANAO WAY STE 315
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-7907
Practice Address - Country:US
Practice Address - Phone:310-301-6310
Practice Address - Fax:310-301-6315
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA195499208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics