Provider Demographics
NPI:1518015494
Name:GURBANI, MEENA SURESH (MD)
Entity Type:Individual
Prefix:
First Name:MEENA
Middle Name:SURESH
Last Name:GURBANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 CARNEGIE DR.
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408
Mailing Address - Country:US
Mailing Address - Phone:909-890-0407
Mailing Address - Fax:909-890-0575
Practice Address - Street 1:1505 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1202
Practice Address - Country:US
Practice Address - Phone:909-887-6494
Practice Address - Fax:909-887-6043
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55112208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A551120Medicaid