Healthcare Provider Details

I. General information

NPI: 1003154246
Provider Name (Legal Business Name): SUNITA RAVINDER IDNANI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 TERMINO AVE SUITE 206
LONG BEACH CA
90804-2124
US

IV. Provider business mailing address

19301 SURFVIEW DR
HUNTINGTON BEACH CA
92648-5588
US

V. Phone/Fax

Practice location:
  • Phone: 562-961-0210
  • Fax: 562-961-0212
Mailing address:
  • Phone: 714-791-9540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA56016
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: