Provider Demographics
NPI:1043281108
Name:SR ABHYANKAR MD PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:SR ABHYANKAR MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SHREEDHAR RAMESH
Authorized Official - Middle Name:P
Authorized Official - Last Name:ABHYANKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-347-0440
Mailing Address - Street 1:81709 DR CARREON BLVD
Mailing Address - Street 2:STE C 1
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5509
Mailing Address - Country:US
Mailing Address - Phone:760-347-0440
Mailing Address - Fax:760-342-0747
Practice Address - Street 1:81709 DR CARREON BLVD
Practice Address - Street 2:STE C 1
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5509
Practice Address - Country:US
Practice Address - Phone:760-347-0440
Practice Address - Fax:760-342-0747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42869174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102750Medicaid
CAZZZ01527ZMedicare PIN
CAGR0102750Medicaid