Provider Demographics
NPI:1770563116
Name:DAMLE, PRADEEP BALKRISHNA (MD)
Entity type:Individual
Prefix:DR
First Name:PRADEEP
Middle Name:BALKRISHNA
Last Name:DAMLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 W AVENUE J
Mailing Address - Street 2:STE 101
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2942
Mailing Address - Country:US
Mailing Address - Phone:661-945-8717
Mailing Address - Fax:661-945-4867
Practice Address - Street 1:1331 W AVENUE J
Practice Address - Street 2:STE 101
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2942
Practice Address - Country:US
Practice Address - Phone:661-945-8717
Practice Address - Fax:661-945-4867
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36983174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A369830Medicaid
CA00A369830Medicaid
CAWA36983DMedicare ID - Type Unspecified