Provider Demographics
NPI:1659350916
Name:MAHAJAN, SUMIT (MD)
Entity type:Individual
Prefix:
First Name:SUMIT
Middle Name:
Last Name:MAHAJAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1600
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92286-1600
Mailing Address - Country:US
Mailing Address - Phone:760-228-1114
Mailing Address - Fax:
Practice Address - Street 1:57402 29 PALMS HWY STE 5
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-2957
Practice Address - Country:US
Practice Address - Phone:760-228-1114
Practice Address - Fax:760-228-2066
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80732207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A807320Medicaid
CA00A807320Medicaid
CA00A807322Medicare PIN