Healthcare Provider Details

I. General information

NPI: 1013515287
Provider Name (Legal Business Name): BALWIN PARK MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2020
Last Update Date: 11/15/2020
Certification Date: 11/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14652 PACIFIC AVE
BALDWIN PARK CA
91706-5333
US

IV. Provider business mailing address

14652 PACIFIC AVE
BALDWIN PARK CA
91706-5333
US

V. Phone/Fax

Practice location:
  • Phone: 626-337-1360
  • Fax: 323-962-1375
Mailing address:
  • Phone: 626-337-1360
  • Fax: 626-962-1375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ERRAJITH BERTRAND R DE SILVA
Title or Position: MEDICAL DIRECTOR
Credential: MEDICAL DOCTOR
Phone: 714-673-2603