MEDICARE: USHA IDNANI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A54509	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CO026	OTHER	CA	MEDICARE INCENTIVE PROGRAM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CO026	OTHER	CA	PTAN
3	A54509	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1861446056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	USHA IDNANI M.D.

Provider Business Mailing Address
First Line	:	34052 LA PLAZA STREET
Second Line	:	STE 105
City	:	DANA POINT
State	:	CA
Zip	:	92629-0000
Country	:	US
Telephone Number	:	949-276-6499
Fax Number	:	949-276-6498

Provider Business Practice Location Address
First Line	:	34052 LA PLAZA STREET
Second Line	:	STE 105
City	:	DANA POINT
State	:	CA
Zip	:	92629-0000
Country	:	US
Telephone Number	:	949-276-6499
Fax Number	:	949-276-6498

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	02/22/2013

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