Healthcare Provider Details

I. General information

NPI: 1679836084
Provider Name (Legal Business Name): DHP OF CALIFORNIA MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 05/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W AVENUE J
LANCASTER CA
93534-2814
US

IV. Provider business mailing address

265 BROOKVIEW CENTRE WAY SUITE 400
KNOXVILLE TN
37919-4052
US

V. Phone/Fax

Practice location:
  • Phone: 661-949-5000
  • Fax:
Mailing address:
  • Phone: 865-693-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SUJAL MANDAVIA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 865-693-1000