Provider Demographics
NPI:1962719146
Name:SRIVALI TEAL, JUTARA (LAC)
Entity type:Individual
Prefix:
First Name:JUTARA
Middle Name:
Last Name:SRIVALI TEAL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2933 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1414
Mailing Address - Country:US
Mailing Address - Phone:562-896-3685
Mailing Address - Fax:562-595-5682
Practice Address - Street 1:3815 ATLANTIC AVE
Practice Address - Street 2:#5
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3500
Practice Address - Country:US
Practice Address - Phone:562-896-3685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2010-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13184208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice