Healthcare Provider Details

I. General information

NPI: 1205835634
Provider Name (Legal Business Name): SMITA BHARGAVA TANDON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 WARNER AVE STE 368
FOUNTAIN VALLEY CA
92708-7514
US

IV. Provider business mailing address

11100 WARNER AVE STE 368
FOUNTAIN VALLEY CA
92708-7514
US

V. Phone/Fax

Practice location:
  • Phone: 714-241-1777
  • Fax: 714-241-7221
Mailing address:
  • Phone: 714-241-1777
  • Fax: 714-241-7221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA49104
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: