Healthcare Provider Details

I. General information

NPI: 1144549049
Provider Name (Legal Business Name): PRABHA DHALLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 MARKET ST SUITE A
RIVERSIDE CA
92501-3567
US

IV. Provider business mailing address

4343 MARKET ST SUITE A
RIVERSIDE CALIFORNIA
92501
UM

V. Phone/Fax

Practice location:
  • Phone: 951-787-4880
  • Fax: 951-787-8628
Mailing address:
  • Phone: 951-787-4880
  • Fax: 951-787-8628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA35185
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: