Basic Information
| Provider Information | |||||||||
| NPI: | 1467639880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANDKHOROVA | ||||||||
| FirstName: | NELLYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHAMALOVA | ||||||||
| OtherFirstName: | NELLYA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 314 N. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932573730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597917000 | ||||||||
| FaxNumber: | 5597821418 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 W. POPLAR AVE. | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932575839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597817242 | ||||||||
| FaxNumber: | 5597828259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2008 | ||||||||
| LastUpdateDate: | 07/02/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 247416 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | A107129 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.