Basic Information
| Provider Information | |||||||||
| NPI: | 1104118439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARUGUNDLA | ||||||||
| FirstName: | PRATHIMA | ||||||||
| MiddleName: | SMRUTHI | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | ATTN CREDENTIALING/PAYER ENROLLMENT | ||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956702354 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 18406 ROSCOE BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913254107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188858500 | ||||||||
| FaxNumber: | 8187270793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2011 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A12826 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 20A12826 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.