Healthcare Provider Details

I. General information

NPI: 1104010073
Provider Name (Legal Business Name): DR SUKHDEEP K GREWAL M.D.INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 04/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 S BRISTOL ST
SANTA ANA CA
92704-6201
US

IV. Provider business mailing address

PO BOX 28572
SANTA ANA CA
92799-8572
US

V. Phone/Fax

Practice location:
  • Phone: 714-754-5503
  • Fax:
Mailing address:
  • Phone: 949-500-0198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberA52636
License Number StateCA

VIII. Authorized Official

Name: DR. SUKHDEEP K GREWAL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-500-0198