Provider Demographics
NPI:1922297209
Name:JASDEEP S BAL MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JASDEEP S BAL MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASDEEP
Authorized Official - Middle Name:S
Authorized Official - Last Name:BAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-835-5396
Mailing Address - Street 1:3385 BORDEAUX DR
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-3984
Mailing Address - Country:US
Mailing Address - Phone:916-835-5396
Mailing Address - Fax:
Practice Address - Street 1:3385 BORDEAUX DR
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-3984
Practice Address - Country:US
Practice Address - Phone:916-835-5396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A812395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02409ZMedicare PIN