Basic Information
| Provider Information | |||||||||
| NPI: | 1134410103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAVISETTY | ||||||||
| FirstName: | SUPRIYA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9602 | ||||||||
| Address2: | |||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913469602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188375559 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11333 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183659531 | ||||||||
| FaxNumber: | 8188981682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2011 | ||||||||
| LastUpdateDate: | 09/29/2015 | ||||||||
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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 | 208000000X | A122963 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 001229630 | 05 | CA | MEDICAID |