Healthcare Provider Details

I. General information

NPI: 1891008736
Provider Name (Legal Business Name): KOMAL SURYAWALA RDMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 E STEARNS ST
BREA CA
92821-4745
US

IV. Provider business mailing address

2999 E STEARNS ST
BREA CA
92821-4745
US

V. Phone/Fax

Practice location:
  • Phone: 714-457-9284
  • Fax:
Mailing address:
  • Phone: 714-457-9284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number96182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: