Healthcare Provider Details

I. General information

NPI: 1285675314
Provider Name (Legal Business Name): GAGANDEEP GREWAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 11/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N TUSTIN AVE EMERGENCY DEPARTMENT
SANTA ANA CA
92705-3502
US

IV. Provider business mailing address

4551 GLENCOE AVE SUITE 260
MARINA DEL REY CA
90292-6385
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-3500
  • Fax:
Mailing address:
  • Phone: 310-301-2030
  • Fax: 310-306-5247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA68101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: