Healthcare Provider Details

I. General information

NPI: 1306058151
Provider Name (Legal Business Name): MANDEEP SINGH GHUMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18460 ROSCOE BLVD FL 2
NORTHRIDGE CA
91325-4107
US

IV. Provider business mailing address

3400 DATA DR ATTN CREDENTIALING/PAYER ENROLLMENT
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 818-885-5480
  • Fax: 818-993-1917
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA108800
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA108800
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: