Healthcare Provider Details

I. General information

NPI: 1962625384
Provider Name (Legal Business Name): SANDHYA R GUDAPATI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 06/02/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E. COMMONWEALTH AVE. SUITE 101
FULLERTON CA
92832-3616
US

IV. Provider business mailing address

140 E. COMMONWEALTH AVE. SUITE 101
FULLERTON CA
92832-3616
US

V. Phone/Fax

Practice location:
  • Phone: 714-773-4111
  • Fax: 714-773-4222
Mailing address:
  • Phone: 714-773-4111
  • Fax: 714-773-4222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA46239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: