Healthcare Provider Details

I. General information

NPI: 1881332732
Provider Name (Legal Business Name): GOPU PREMRAJAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2022
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 E LINCOLN AVE
ANAHEIM CA
92805-4345
US

IV. Provider business mailing address

16702 VALLEY VIEW AVE
LA MIRADA CA
90638-5824
US

V. Phone/Fax

Practice location:
  • Phone: 714-635-2642
  • Fax:
Mailing address:
  • Phone: 714-367-5391
  • Fax: 714-635-5428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA209283
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberA209283
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: