Healthcare Provider Details

I. General information

NPI: 1720042336
Provider Name (Legal Business Name): MANMOHAN GURSAHANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 FERNDALE AVE
FULLERTON CA
92831
US

IV. Provider business mailing address

1211 W LA PALMA AVE STE 502
ANAHEIM CA
92801-2812
US

V. Phone/Fax

Practice location:
  • Phone: 559-241-4513
  • Fax:
Mailing address:
  • Phone: 714-267-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberC51339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: