Provider Demographics
NPI:1780868968
Name:SUBBARAO MYLAVARAPU, MD, A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:SUBBARAO MYLAVARAPU, MD, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUBBARAO
Authorized Official - Middle Name:V
Authorized Official - Last Name:MYLAVARAPU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-722-2411
Mailing Address - Street 1:351 HOSPITAL ROAD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3508
Mailing Address - Country:US
Mailing Address - Phone:949-722-2411
Mailing Address - Fax:949-650-4966
Practice Address - Street 1:351 HOSPITAL ROAD
Practice Address - Street 2:SUITE 610
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3508
Practice Address - Country:US
Practice Address - Phone:949-722-2411
Practice Address - Fax:949-650-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA044935207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15671Medicare PIN
CAA61318Medicare UPIN