Provider Demographics
NPI:1689865776
Name:BORWORN RATTIDHAM,MD.,P.C.
Entity Type:Organization
Organization Name:BORWORN RATTIDHAM,MD.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BORWORN
Authorized Official - Middle Name:
Authorized Official - Last Name:RATTIDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-943-8110
Mailing Address - Street 1:126 AVOCADO AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-2605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 AVOCADO AVE STE 102
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2605
Practice Address - Country:US
Practice Address - Phone:951-943-8110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25955261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24647Medicare UPIN