Provider Demographics
NPI:1861446056
Name:IDNANI, USHA (MD)
Entity Type:Individual
Prefix:
First Name:USHA
Middle Name:
Last Name:IDNANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:USHA
Other - Middle Name:
Other - Last Name:GOPAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:34052 LA PLAZA STREET
Mailing Address - Street 2:STE 105
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-0000
Mailing Address - Country:US
Mailing Address - Phone:949-276-6499
Mailing Address - Fax:949-276-6498
Practice Address - Street 1:34052 LA PLAZA STREET
Practice Address - Street 2:STE 105
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-0000
Practice Address - Country:US
Practice Address - Phone:949-276-6499
Practice Address - Fax:949-276-6498
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACO026OtherMEDICARE INCENTIVE PROGRAM
CACO026OtherPTAN
CAA54509OtherSTATE LICENSE
CAA54509OtherSTATE LICENSE