Provider Demographics
NPI:1649053026
Name:JAMBUSARIA, SAGAR
Entity type:Individual
Prefix:
First Name:SAGAR
Middle Name:
Last Name:JAMBUSARIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 PASEO LUNA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6501
Mailing Address - Country:US
Mailing Address - Phone:949-201-7845
Mailing Address - Fax:
Practice Address - Street 1:2790 HARBOR BLVD STE 300
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5157
Practice Address - Country:US
Practice Address - Phone:714-427-0803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist