Provider Demographics
NPI:1487018990
Name:LAND PARK PEDIATRIC MEDICAL GROUP
Entity Type:Organization
Organization Name:LAND PARK PEDIATRIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAVINDER
Authorized Official - Middle Name:SINGH
Authorized Official - Last Name:KHAIRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-422-7273
Mailing Address - Street 1:4617 FREEPORT BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-2015
Mailing Address - Country:US
Mailing Address - Phone:916-422-7273
Mailing Address - Fax:916-422-2127
Practice Address - Street 1:4617 FREEPORT BLVD STE B
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95822-2015
Practice Address - Country:US
Practice Address - Phone:916-422-7273
Practice Address - Fax:916-422-2127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56390208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty