Healthcare Provider Details

I. General information

NPI: 1972248441
Provider Name (Legal Business Name): RAVINDER SINGH BAJWA, M.D, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 04/29/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4904 TELEGRAPH RD
VENTURA CA
93003-4109
US

IV. Provider business mailing address

5302 CALAROSA RANCH RD
CAMARILLO CA
93012-2541
US

V. Phone/Fax

Practice location:
  • Phone: 805-642-4101
  • Fax:
Mailing address:
  • Phone: 951-461-9573
  • Fax: 951-304-3653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TRACY GALLO
Title or Position: THIRD PARTY ADMINISTRATOR
Credential:
Phone: 951-461-9573