Healthcare Provider Details

I. General information

NPI: 1124248844
Provider Name (Legal Business Name): BALDEV S RAI MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 09/09/2022
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 RIVERWALK PKWY STE 280
RIVERSIDE CA
92505-3370
US

IV. Provider business mailing address

4234 RIVERWALK PKWY STE 280
RIVERSIDE CA
92505-3370
US

V. Phone/Fax

Practice location:
  • Phone: 951-785-7190
  • Fax: 951-688-7246
Mailing address:
  • Phone: 951-785-7190
  • Fax: 951-688-7246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberA41709
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License NumberA41709
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: JESSICA R DOMINGUEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 951-785-7190