Provider Demographics
NPI:1801349683
Name:BANGALORE, ARCHANA
Entity type:Individual
Prefix:
First Name:ARCHANA
Middle Name:
Last Name:BANGALORE
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 1:21890 W COLORADO AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN JOAQUIN
Mailing Address - State:CA
Mailing Address - Zip Code:93660
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3746
Practice Address - Country:US
Practice Address - Phone:559-203-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA157666207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine