Healthcare Provider Details

I. General information

NPI: 1083747653
Provider Name (Legal Business Name): PREM GOPALDAS LALWANI OTR CHT CSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 GLENVIEW DR
MILPITAS CA
95035-6668
US

IV. Provider business mailing address

2305 GLENVIEW DR
MILPITAS CA
95035-6668
US

V. Phone/Fax

Practice location:
  • Phone: 408-887-3149
  • Fax: 408-956-1064
Mailing address:
  • Phone: 408-887-3149
  • Fax: 408-956-1064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberOT 137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: