Provider Demographics
NPI:1780841841
Name:KESANAPALLI PEDIATRICS PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:KESANAPALLI PEDIATRICS PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEEPTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:KESANAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-576-8010
Mailing Address - Street 1:7910 FROST STREET
Mailing Address - Street 2:SUITE 335
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2771
Mailing Address - Country:US
Mailing Address - Phone:858-576-8010
Mailing Address - Fax:858-576-7391
Practice Address - Street 1:7910 FROST STREET
Practice Address - Street 2:SUITE 335
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2771
Practice Address - Country:US
Practice Address - Phone:858-576-8010
Practice Address - Fax:858-576-7391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56064208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA560640Medicaid
CAZZZ01416ZOtherBLUE SHIELD