Provider Demographics
NPI:1285893966
Name:ACHANTA, LATHA MADHAVI (MD MPH)
Entity type:Individual
Prefix:
First Name:LATHA
Middle Name:MADHAVI
Last Name:ACHANTA
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 FOOTHILL BLVD STE B262
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2901
Mailing Address - Country:US
Mailing Address - Phone:909-901-3087
Mailing Address - Fax:
Practice Address - Street 1:2105 FOOTHILL BLVD STE B262
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2901
Practice Address - Country:US
Practice Address - Phone:909-901-3087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC180509207R00000X
ART2010-091207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5AE01Medicare PIN