Healthcare Provider Details

I. General information

NPI: 1184612061
Provider Name (Legal Business Name): SUDHA GOVINDARAJAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E BEVERLY BLVD STE 302
MONTEBELLO CA
90640-4300
US

IV. Provider business mailing address

101 E BEVERLY BLVD STE 302
MONTEBELLO CA
90640-4300
US

V. Phone/Fax

Practice location:
  • Phone: 323-728-8181
  • Fax: 323-724-9725
Mailing address:
  • Phone: 323-728-8181
  • Fax: 323-724-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA36370
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: