Healthcare Provider Details

I. General information

NPI: 1467487983
Provider Name (Legal Business Name): CARDIOLOGY SPECIALISTS MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/24/2023
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3770 ELIZABETH ST
RIVERSIDE CA
92506-2527
US

IV. Provider business mailing address

3770 ELIZABETH ST
RIVERSIDE CA
92506-2527
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-3937
  • Fax: 951-352-2839
Mailing address:
  • Phone: 951-352-3937
  • Fax: 951-352-2839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA43218
License Number StateCA

VIII. Authorized Official

Name: DR. KAUSTUBH VASANT PATANKAR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-352-3937