Healthcare Provider Details

I. General information

NPI: 1104939172
Provider Name (Legal Business Name): SWAPNA S. KUDTARKAR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E HIGHLAND AVE STE 450A
SAN BERNARDINO CA
92404-3803
US

IV. Provider business mailing address

3400 DATA DR
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 909-864-4700
  • Fax: 909-883-0459
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA067887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: