Provider Demographics
NPI:1376579664
Name:GULATI, RAJEEV (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJEEV
Middle Name:
Last Name:GULATI
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 1:1070 FULLER DR
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-1496
Mailing Address - Country:US
Mailing Address - Phone:909-865-1161
Mailing Address - Fax:909-865-1737
Practice Address - Street 1:255 E BONITA AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1923
Practice Address - Country:US
Practice Address - Phone:909-865-1161
Practice Address - Fax:909-865-1737
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073175208G00000X
VA0101256928208G00000X
CAG86583208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G865860Medicaid
VA0101256928OtherLICENSE
VA1376579664Medicaid
CA00G865860Medicaid
VAFG4763290OtherDEA
CAG86583Medicare PIN
VA0101256928OtherLICENSE
VAVVE773BMedicare PIN