Basic Information
| Provider Information | |||||||||
| NPI: | 1730157876 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DHALLA | ||||||||
| FirstName: | RAJA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4343 MARKET ST | ||||||||
| Address2: | STE A | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925013567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093981550 | ||||||||
| FaxNumber: | 9093981573 | ||||||||
| Practice Location | |||||||||
| Address1: | 1866 N ORANGE GROVE AVE | ||||||||
| Address2: | STE 202 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096238796 | ||||||||
| FaxNumber: | 9096233076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 01/04/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | A73993 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | A73993 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A739930 | 05 | CA | MEDICAID |