Provider Demographics
NPI:1245525690
Name:SANATHRA, MAHENDRA G (MD)
Entity type:Individual
Prefix:
First Name:MAHENDRA
Middle Name:G
Last Name:SANATHRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 E. FLORENCE AVE.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-2754
Mailing Address - Country:US
Mailing Address - Phone:323-581-0000
Mailing Address - Fax:323-585-4030
Practice Address - Street 1:2015 E. FLORENCE AVE.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-2754
Practice Address - Country:US
Practice Address - Phone:323-581-0000
Practice Address - Fax:323-585-4030
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50182207QA0505X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A501821Medicaid
CAA50182OtherSTATE LICENSE
CA00A501821Medicaid