Provider Demographics
NPI:1285716357
Name:PRAVEENA SARMA MD MEDICAL CORP
Entity type:Organization
Organization Name:PRAVEENA SARMA MD MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PRAVEENA
Authorized Official - Middle Name:N
Authorized Official - Last Name:SARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-833-0998
Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95258-0986
Mailing Address - Country:US
Mailing Address - Phone:209-362-5539
Mailing Address - Fax:888-228-7108
Practice Address - Street 1:652 W 11TH ST STE 137
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3869
Practice Address - Country:US
Practice Address - Phone:209-362-5539
Practice Address - Fax:888-228-7108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61533207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A615331Medicaid
CA00A615331Medicaid
G21330Medicare UPIN