Basic Information
| Provider Information | |||||||||
| NPI: | 1285658807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IYER | ||||||||
| FirstName: | KANAKAVALLI | ||||||||
| MiddleName: | SURESH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7001 | ||||||||
| Address2: | 1000 | ||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913577001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188887815 | ||||||||
| FaxNumber: | 8187151722 | ||||||||
| Practice Location | |||||||||
| Address1: | 2975 SYCAMORE DR | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930651201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059556900 | ||||||||
| FaxNumber: | 8059556063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A56234 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A562340 | 01 | CA | BLUE SHIELD | OTHER | 00A562340 | 05 | CA | MEDICAID |