Provider Demographics
NPI:1386976249
Name:GORADIA MEDICAL CORPORATION
Entity type:Organization
Organization Name:GORADIA MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TUSHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GORADIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:916-534-1234
Mailing Address - Street 1:PO BOX 39000
Mailing Address - Street 2:DEPT# 34304
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94139-0001
Mailing Address - Country:US
Mailing Address - Phone:916-534-1234
Mailing Address - Fax:
Practice Address - Street 1:4003 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7503
Practice Address - Country:US
Practice Address - Phone:916-534-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86829207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689782484OtherNPI
CA1689782484OtherNPI