Healthcare Provider Details

I. General information

NPI: 1295013712
Provider Name (Legal Business Name): MUKESH BHOGILAL SUTHAR MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10808 FOOTHILL BLVD STE 160-203
RANCHO CUCAMONGA CA
91730-3889
US

IV. Provider business mailing address

10808 FOOTHILL BLVD STE 160-203
RANCHO CUCAMONGA CA
91730-3889
US

V. Phone/Fax

Practice location:
  • Phone: 909-660-3003
  • Fax:
Mailing address:
  • Phone: 909-660-3003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG86105
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MUKESH BHOGILAL SUTHAR
Title or Position: OWNER
Credential: MD
Phone: 909-660-3003