Provider Demographics
NPI:1811072978
Name:JEGAPRAGASAN, VANNITHAMBY (MD)
Entity type:Individual
Prefix:
First Name:VANNITHAMBY
Middle Name:
Last Name:JEGAPRAGASAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12660 RIVERSIDE DR STE 310320
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3429
Mailing Address - Country:US
Mailing Address - Phone:818-755-0391
Mailing Address - Fax:
Practice Address - Street 1:12660 RIVERSIDE DR STE 310320
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3429
Practice Address - Country:US
Practice Address - Phone:818-755-0391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00133525OtherRAILROAD
CA00A540470Medicaid
CA00A540470Medicare PIN
CAG12100Medicare UPIN