Provider Demographics
NPI:1841583424
Name:BALDERRAMA MEDICAL CLINIC
Entity Type:Organization
Organization Name:BALDERRAMA MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:BALDERRAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-908-8000
Mailing Address - Street 1:14342 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1944
Mailing Address - Country:US
Mailing Address - Phone:818-908-8000
Mailing Address - Fax:
Practice Address - Street 1:14342 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1944
Practice Address - Country:US
Practice Address - Phone:818-908-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB50323Medicare UPIN
CAA28820Medicare UPIN