Provider Demographics
NPI:1316999550
Name:MUMMANENI, MADHAVI (MD)
Entity type:Individual
Prefix:
First Name:MADHAVI
Middle Name:
Last Name:MUMMANENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 W LA VETA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3928
Mailing Address - Country:US
Mailing Address - Phone:714-835-1800
Mailing Address - Fax:714-835-1811
Practice Address - Street 1:805 W LA VETA AVE STE 101
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3928
Practice Address - Country:US
Practice Address - Phone:714-628-3136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52454207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A524540734Medicaid
WA52454AOtherPPIN
W969Medicare ID - Type UnspecifiedGROUP #
CA00A524540734Medicaid