Provider Demographics
NPI:1548458706
Name:HIREGOUDAR, MAMATHA (MD)
Entity type:Individual
Prefix:DR
First Name:MAMATHA
Middle Name:
Last Name:HIREGOUDAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 W MACARTHUR BLVD
Mailing Address - Street 2:#203
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5642
Mailing Address - Country:US
Mailing Address - Phone:805-300-2340
Mailing Address - Fax:
Practice Address - Street 1:280 W MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5642
Practice Address - Country:US
Practice Address - Phone:805-300-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 101765207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA 101765OtherMEDICAL BOARD OF CA