Provider Demographics
NPI:1154514677
Name:KUMARAVELU, PRIYA GOMATHI (MD)
Entity type:Individual
Prefix:
First Name:PRIYA
Middle Name:GOMATHI
Last Name:KUMARAVELU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:175 N JACKSON AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1909
Mailing Address - Country:US
Mailing Address - Phone:408-203-4945
Mailing Address - Fax:408-516-9985
Practice Address - Street 1:175 N JACKSON AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1909
Practice Address - Country:US
Practice Address - Phone:408-203-4945
Practice Address - Fax:408-516-9985
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301086299207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAQ125XMedicare PIN