Provider Demographics
NPI:1285788398
Name:VALLEY PEDIATRIC PULMONARY MEDICAL CORP.
Entity type:Organization
Organization Name:VALLEY PEDIATRIC PULMONARY MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC PULMONOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUDHAKAR
Authorized Official - Middle Name:L
Authorized Official - Last Name:REDDIVALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-353-5550
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-5550
Mailing Address - Fax:559-353-5587
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-8761
Practice Address - Country:US
Practice Address - Phone:559-353-5550
Practice Address - Fax:559-353-5587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2080P0214X2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49339OtherCA LICENSE #
CAGR0103350Medicaid
CAA49421OtherCA LICENSE #
CAA76613OtherCA LICENSE #
CA=========OtherGROUP TAX ID#