Healthcare Provider Details

I. General information

NPI: 1861446056
Provider Name (Legal Business Name): USHA IDNANI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: USHA GOPAL MD

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34052 LA PLAZA STREET STE 105
DANA POINT CA
92629-0000
US

IV. Provider business mailing address

34052 LA PLAZA STREET STE 105
DANA POINT CA
92629-0000
US

V. Phone/Fax

Practice location:
  • Phone: 949-276-6499
  • Fax: 949-276-6498
Mailing address:
  • Phone: 949-276-6499
  • Fax: 949-276-6498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA54509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: