Healthcare Provider Details

I. General information

NPI: 1417054230
Provider Name (Legal Business Name): MISS CHITRA BHAKTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 S FETTERLY AVE
LOS ANGELES CA
90022-1605
US

IV. Provider business mailing address

1525 SUPERIOR AVE STE 206
NEWPORT BEACH CA
92663-3639
US

V. Phone/Fax

Practice location:
  • Phone: 323-780-2216
  • Fax: 323-264-3771
Mailing address:
  • Phone: 949-642-3333
  • Fax: 949-242-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA063631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: