Healthcare Provider Details

I. General information

NPI: 1770748030
Provider Name (Legal Business Name): PRABHJOT KAUR GREWAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6848 MAGNOLIA AVE STE 125
RIVERSIDE CA
92506-2899
US

IV. Provider business mailing address

71780 SAN JACINTO DR BLDG I
RANCHO MIRAGE CA
92270-5516
US

V. Phone/Fax

Practice location:
  • Phone: 951-289-9512
  • Fax: 951-394-8438
Mailing address:
  • Phone: 760-568-3461
  • Fax: 760-423-6273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA89940
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: