Basic Information
| Provider Information | |||||||||
| NPI: | 1518015494 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GURBANI | ||||||||
| FirstName: | MEENA | ||||||||
| MiddleName: | SURESH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 685 CARNEGIE DR. | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098900407 | ||||||||
| FaxNumber: | 9098900575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 W 17TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924111202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098876494 | ||||||||
| FaxNumber: | 9098876043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A55112 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00A551120 | 05 | CA | MEDICAID |