Provider Demographics
NPI:1730261488
Name:DASARI, PADMA (M D)
Entity type:Individual
Prefix:MRS
First Name:PADMA
Middle Name:
Last Name:DASARI
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 PENNSYLVANIA AVE STE D
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3509
Mailing Address - Country:US
Mailing Address - Phone:707-421-2229
Mailing Address - Fax:707-438-3764
Practice Address - Street 1:1620 PENNSYLVANIA AVE STE D
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3509
Practice Address - Country:US
Practice Address - Phone:707-421-2229
Practice Address - Fax:707-438-3764
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF18630Medicare UPIN