Healthcare Provider Details

I. General information

NPI: 1336529148
Provider Name (Legal Business Name): I S GUJRAL MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24953 PASEO DE VALENCIA STE 30A
LAGUNA HILLS CA
92653-4343
US

IV. Provider business mailing address

18 NEWCASTLE LN
LAGUNA NIGUEL CA
92677-9327
US

V. Phone/Fax

Practice location:
  • Phone: 949-716-7981
  • Fax: 949-716-7982
Mailing address:
  • Phone: 949-307-2315
  • Fax: 949-716-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA49536
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberA49536
License Number StateCA

VIII. Authorized Official

Name: NICOLETTE GONZALEZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 951-340-1000