Active NPI
Anisha Krishnan Thondukolam, DDS
- Periodontics
- San Ramon, CA
National Provider Identifier
1609109768
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- 62123
- Practice address
- 591 Fallen Leaf Cir
San Ramon, CA 94583-5305 - Phone
- (510) 604-5776
- NPI assigned
- Sep 8, 2009
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 62123 | CA | Primary |
Addresses
Primary practice location
591 Fallen Leaf Cir
San Ramon, CA 94583-5305
Mailing address
591 Fallen Leaf Cir
San Ramon, CA 94583-5305
Phone (510) 604-5776
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20171226000652 | CA | Order and Referring Only - Other (Physician) | 6002174992 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 62123 | CA | MD | Pharmacist |
Interoperability endpoints
- athondukolam@direct.westerndental.com
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1252368000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1364774400000",
"number": "1609109768",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "591 FALLEN LEAF CIR",
"city": "SAN RAMON",
"state": "CA",
"postal_code": "945835305",
"telephone_number": "510-604-5776"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "591 FALLEN LEAF CIR",
"city": "SAN RAMON",
"state": "CA",
"postal_code": "945835305",
"telephone_number": "510-604-5776"
}
],
"practiceLocations": [],
"basic": {
"last_name": "THONDUKOLAM",
"first_name": "ANISHA",
"middle_name": "KRISHNAN",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2009-09-08",
"last_updated": "2013-04-01",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "CA",
"license": "62123",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Ramon, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 1, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.