Provider Demographics
NPI:1053756924
Name:MORISETTI, PHANI PURUSHOTHAM (MD)
Entity type:Individual
Prefix:
First Name:PHANI
Middle Name:PURUSHOTHAM
Last Name:MORISETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E MARCH LN STE B265
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6655
Mailing Address - Country:US
Mailing Address - Phone:209-546-1868
Mailing Address - Fax:209-461-6505
Practice Address - Street 1:1801 E MARCH LN STE B265
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6655
Practice Address - Country:US
Practice Address - Phone:209-546-1868
Practice Address - Fax:209-461-6505
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2023-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA302690207R00000X, 207RN0300X
390200000X
CAC184332207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program