Healthcare Provider Details

I. General information

NPI: 1245377415
Provider Name (Legal Business Name): RUVDEEP S. RANDHAWA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S MAIN ST
ORANGE CA
92868-3835
US

IV. Provider business mailing address

455 S MAIN ST
ORANGE CA
92868-3835
US

V. Phone/Fax

Practice location:
  • Phone: 714-532-8634
  • Fax: 714-289-4049
Mailing address:
  • Phone: 714-532-8634
  • Fax: 714-289-4049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberA79420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: