Provider Demographics
NPI:1174512263
Name:BHALLA, RAVI (MD)
Entity Type:Individual
Prefix:DR
First Name:RAVI
Middle Name:
Last Name:BHALLA
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 1:13943 N. 91ST AVE
Mailing Address - Street 2:BUILDING I
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3692
Mailing Address - Country:US
Mailing Address - Phone:623-815-2690
Mailing Address - Fax:623-815-2689
Practice Address - Street 1:13943 N. 91ST AVE
Practice Address - Street 2:BUILDING I
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3692
Practice Address - Country:US
Practice Address - Phone:623-815-2690
Practice Address - Fax:623-815-2689
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22399207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ22399OtherLICENSE
AZ172651Medicaid
AZ22399OtherLICENSE
ASZ63630Medicare ID - Type UnspecifiedMEDICARE
AZZ63630Medicare PIN