Healthcare Provider Details

I. General information

NPI: 1275113755
Provider Name (Legal Business Name): RAVEENA BAKHRU DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 W 6TH ST STE 205
SAN PEDRO CA
90732-3567
US

IV. Provider business mailing address

1360 W 6TH ST STE 205
SAN PEDRO CA
90732-3567
US

V. Phone/Fax

Practice location:
  • Phone: 310-833-3135
  • Fax:
Mailing address:
  • Phone: 310-833-3135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberSL1690
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A22759
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number20A22759
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: