Basic Information
Provider Information | |||||||||
NPI: | 1235161795 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BURHAN | ||||||||
FirstName: | NINDYA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10470 OLD PLACERVILLE RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958272539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004700071 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 480 PLUMAS BLVD | ||||||||
Address2: |   | ||||||||
City: | YUBA CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 959915005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5307493326 | ||||||||
FaxNumber: | 5307493197 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 07/02/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G74826 | CA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | BB3483966 | 01 | CA | DEA | OTHER | P00785474 | 01 |   | RAILROAD MEDICARE | OTHER | 1235161795 | 05 | CA |   | MEDICAID |