Provider Demographics
NPI:1285675314
Name:GREWAL, GAGANDEEP (MD)
Entity Type:Individual
Prefix:
First Name:GAGANDEEP
Middle Name:
Last Name:GREWAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 GLENCOE AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6385
Mailing Address - Country:US
Mailing Address - Phone:310-301-2030
Mailing Address - Fax:310-306-5247
Practice Address - Street 1:1001 N TUSTIN AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3502
Practice Address - Country:US
Practice Address - Phone:714-953-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68101207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA68101AMedicare PIN
CAH21035Medicare UPIN