Provider Demographics
NPI:1558502625
Name:HAYWARD PEDIATRIC MEDICAL CLINIC
Entity Type:Organization
Organization Name:HAYWARD PEDIATRIC MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KAVITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAJARAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-886-8854
Mailing Address - Street 1:21297 FOOTHILL BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-1554
Mailing Address - Country:US
Mailing Address - Phone:510-886-8854
Mailing Address - Fax:510-886-6709
Practice Address - Street 1:21297 FOOTHILL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-1554
Practice Address - Country:US
Practice Address - Phone:510-886-8854
Practice Address - Fax:510-886-6709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31628208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1326055963Medicaid