Provider Demographics
NPI:1538102082
Name:BACA, RALPH MIRAMONTES (MD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:MIRAMONTES
Last Name:BACA
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:PO BOX 660640
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0640
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:18321 CLARK ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3501
Practice Address - Country:US
Practice Address - Phone:818-708-5170
Practice Address - Fax:818-705-2595
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69780207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G697800Medicaid
CAWG69780EMedicare PIN
CAWG69780Medicare PIN
CA00G697800Medicaid