1730157876 NPI number — RAJA DHALLA MD

Table of content: RAJA DHALLA MD (NPI 1730157876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730157876 NPI number — RAJA DHALLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DHALLA
Provider First Name:
RAJA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730157876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4343 MARKET ST
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92501-3567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-398-1550
Provider Business Mailing Address Fax Number:
909-398-1573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1866 N ORANGE GROVE AVE
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
POMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91767-3031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-623-8796
Provider Business Practice Location Address Fax Number:
909-623-3076
Provider Enumeration Date:
03/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  A73993 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XX0005X , with the licence number: A73993 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A739930 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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