Basic Information
| Provider Information | |||||||||
| NPI: | 1093248510 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BHAKTA | ||||||||
| FirstName: | RAVI | ||||||||
| MiddleName: | PRAKASH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16707 BIMINI AVE | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907031642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622298381 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 W CIVIC CENTER DR STE 120 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927032380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148358501 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2017 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A167225 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.