Provider Demographics
NPI:1457305963
Name:RAJU H WADHWA
Entity Type:Organization
Organization Name:RAJU H WADHWA
Other - Org Name:EL SEGUNDO FAMILY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJU
Authorized Official - Middle Name:H
Authorized Official - Last Name:WADHWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-939-1892
Mailing Address - Street 1:855 MANHATTAN BEACH BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-4965
Mailing Address - Country:US
Mailing Address - Phone:310-939-1892
Mailing Address - Fax:310-939-1894
Practice Address - Street 1:855 MANHATTAN BEACH BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-4965
Practice Address - Country:US
Practice Address - Phone:310-939-1892
Practice Address - Fax:310-939-1894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE94153Medicare UPIN
CAW15084Medicare ID - Type Unspecified