Basic Information
| Provider Information | |||||||||
| NPI: | 1457324808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOMMINENI | ||||||||
| FirstName: | BHUPAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD FACP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOMMINENI | ||||||||
| OtherFirstName: | BHUPAL | ||||||||
| OtherMiddleName: | JC BOSE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1330 SAN BERNARDINO ROAD | ||||||||
| Address2: | SUITE G | ||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917864974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099810989 | ||||||||
| FaxNumber: | 9099496214 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 SAN BERNARDINO ROAD | ||||||||
| Address2: | SUITE G | ||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917864974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099810989 | ||||||||
| FaxNumber: | 9099496214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 00A346510 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A346510 | 05 | CA | MEDICAID | 953729807 | 01 | CA | TAX ID | OTHER |