Provider Demographics
NPI:1477623585
Name:DABRAL, MUDIT (MD)
Entity Type:Individual
Prefix:
First Name:MUDIT
Middle Name:
Last Name:DABRAL
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 1:1505 SHEPARD DR
Mailing Address - Street 2:SUIE 105
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-7020
Mailing Address - Country:US
Mailing Address - Phone:805-928-9770
Mailing Address - Fax:805-928-6350
Practice Address - Street 1:1505 SHEPARD DR
Practice Address - Street 2:SUITE 105
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7020
Practice Address - Country:US
Practice Address - Phone:805-928-9770
Practice Address - Fax:805-928-6350
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40705207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A407050OtherBLUE SHIELD
CA00A407050Medicaid
CA770154235 93454 A002OtherCHAMPUS TRICARE PIN
CA0480598OtherAETNA PIN
CA1087OtherCMSP
B50440Medicare UPIN
CA00A407050Medicaid
CAWA40705BMedicare PIN