Provider Demographics
NPI:1700194073
Name:BAMBHANIA MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BAMBHANIA MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIVYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAMBHANIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-242-0600
Mailing Address - Street 1:PO BOX 1139
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92393-1139
Mailing Address - Country:US
Mailing Address - Phone:760-242-0600
Mailing Address - Fax:760-242-0606
Practice Address - Street 1:15962 QUANTICO RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1302
Practice Address - Country:US
Practice Address - Phone:760-242-0600
Practice Address - Fax:760-242-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45672207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ37313ZMedicaid
E58444Medicare UPIN
CAWA45672BMedicare PIN
CAZZZ37313ZMedicaid