Healthcare Provider Details

I. General information

NPI: 1003833948
Provider Name (Legal Business Name): JYOTI MANOHAR BAKHRU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JYOTI BHAG VACHANI M.D.

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3460 KATELLA AVE
LOS ALAMITOS CA
90720-2334
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 562-594-6599
  • Fax: 562-598-6220
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberA44963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: