Provider Demographics
NPI:1740892728
Name:BALBUENA RAMIREZ, OCTAVIO
Entity type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:
Last Name:BALBUENA RAMIREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12029 CLOVER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1003
Mailing Address - Country:US
Mailing Address - Phone:310-408-1629
Mailing Address - Fax:
Practice Address - Street 1:1985 ZONAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-5305
Practice Address - Country:US
Practice Address - Phone:323-442-1468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAINT46603390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program