Provider Demographics
NPI:1205835634
Name:TANDON, SMITA BHARGAVA (MD)
Entity Type:Individual
Prefix:DR
First Name:SMITA
Middle Name:BHARGAVA
Last Name:TANDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11100 WARNER AVE STE 368
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7514
Mailing Address - Country:US
Mailing Address - Phone:714-241-1777
Mailing Address - Fax:714-241-7221
Practice Address - Street 1:11100 WARNER AVE STE 368
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7514
Practice Address - Country:US
Practice Address - Phone:714-241-1777
Practice Address - Fax:714-241-7221
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA49104208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A491041Medicaid
CA1205835634Medicaid