Provider Demographics
NPI:1558639815
Name:GUBBI T MRUTHYUNJAYA
Entity Type:Organization
Organization Name:GUBBI T MRUTHYUNJAYA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:ALEJANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNEJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-364-2229
Mailing Address - Street 1:27800 MEDICAL CENTER RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6049
Mailing Address - Country:US
Mailing Address - Phone:949-364-2229
Mailing Address - Fax:949-364-1104
Practice Address - Street 1:27800 MEDICAL CENTER RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6049
Practice Address - Country:US
Practice Address - Phone:949-364-2229
Practice Address - Fax:949-364-1104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24744261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care