Provider Demographics
NPI:1366983892
Name:SYAM P VUNNAMADALA MEDICAL CORP
Entity type:Organization
Organization Name:SYAM P VUNNAMADALA MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:VUNNAMADALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-491-3928
Mailing Address - Street 1:10 VIA GIADA
Mailing Address - Street 2:
Mailing Address - City:NEWPORT COAST
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1211 W LA PALMA AVE STE 310
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2815
Practice Address - Country:US
Practice Address - Phone:714-491-3928
Practice Address - Fax:714-491-3960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-16
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64189174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A641890Medicaid