Provider Demographics
NPI:1710769203
Name:GOURKAR, RUTUJA (NP)
Entity Type:Individual
Prefix:
First Name:RUTUJA
Middle Name:
Last Name:GOURKAR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 S LAURELTREE DR
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92808-1648
Mailing Address - Country:US
Mailing Address - Phone:714-357-7829
Mailing Address - Fax:
Practice Address - Street 1:13372 NEWPOER AVE
Practice Address - Street 2:#B
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92789
Practice Address - Country:US
Practice Address - Phone:714-544-3430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027253208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics