Healthcare Provider Details

I. General information

NPI: 1093276586
Provider Name (Legal Business Name): JEENA KAUR SANDHU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD STE 480W
SANTA MONICA CA
90404-2121
US

IV. Provider business mailing address

1385 HIDDEN RANCH DR
SIMI VALLEY CA
93063-4564
US

V. Phone/Fax

Practice location:
  • Phone: 310-954-9501
  • Fax: 310-954-9502
Mailing address:
  • Phone: 805-416-3280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01090792A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA198964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: