Basic Information
| Provider Information | |||||||||
| NPI: | 1750353280 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHIVUKULA | ||||||||
| FirstName: | MAMATHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 393 E GRAND AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | SOUTH SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940806233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516162955 | ||||||||
| FaxNumber: | 6507378920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | C54789 | CA | N | Other Service Providers | Specialist | 174400000X | MD424156 | PA | N | Other Service Providers | Specialist | 207ZP0102X | C54789 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 101241039 | 05 | PA | MEDICAID |