Healthcare Provider Details

I. General information

NPI: 1841633575
Provider Name (Legal Business Name): AJAY GURBANI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 16TH ST STE 2100
SANTA MONICA CA
90404
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-319-1234
  • Fax: 424-259-6560
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberA136215
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: