Healthcare Provider Details

I. General information

NPI: 1912103318
Provider Name (Legal Business Name): RAGINI GUMMADAPU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14591 NEWPORT AVE STE 206
TUSTIN CA
92780-6027
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 714-442-4864
  • Fax:
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA97735
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: